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

Effects of chronic physical illness on treatment outcomes among patients with schizophrenia

PURPOSE OF REVIEW

Previous research has demonstrated the high prevalence of medical comorbidity and multimorbidity among patients with schizophrenia. However, little is known regarding the potential effects of chronic physical illness (CPI) on schizophrenia treatment outcomes. In the present report, we aim to provide an updated review of the relevant literature.

RECENT FINDINGS

We searched MEDLINE for studies published between 2017 and 2018. After screening 683 articles, we included six studies of adequate quality. Five of these studies reported significant associations between several CPIs and different schizophrenia treatment outcomes, whereas the remaining study did not. Significant effects were low to moderate in size. CPIs with significant effects on treatment outcomes included metabolic syndrome, cardiovascular disease, and asthma. No significant effects were observed for diabetes, chronic obstructive pulmonary disease, hepatitis, hypertension, hyperlipidemia, or lung conditions. One study reported a significant association between the total number of CPIs and the overall number of psychiatric rehospitalizations.

SUMMARY

In addition to increasing the risk of premature mortality, accumulating evidence indicates that various CPIs affect schizophrenia treatment outcomes. Thus, researchers and healthcare practitioners should increase efforts to raise awareness regarding the importance of physical health among patients with schizophrenia. Further high-quality studies are required, particularly those targeting the potential effects of individual CPIs.

Meta-analysis of natural, unnatural and cause-specific mortality rates following discharge from in-patient psychiatric facilities

BACKGROUND

People discharged from in-patient psychiatric facilities have highly elevated rates of suicide, and there is increasing concern about natural mortality among the seriously mentally ill.

METHOD

A meta-analysis of English-language, peer-reviewed longitudinal studies of mortality among patients discharged from in-patient psychiatric facilities was conducted using papers published in MEDLINE, PsycINFO or EMBASE (from 1 January 1960 to 1 April 2018) located using the terms ((suicid*).ti AND (hospital OR discharg* OR inpatient OR in-patient OR admit*)).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* OR hospital* OR inpatient* OR in-patient* OR discharg*).ab. Pooled mortality rates for aggregated natural and unnatural causes, and the specific causes of suicide, accident, homicide, vascular, neoplastic, respiratory, gastrointestinal, infectious and metabolic death were calculated using a random-effects meta-analytic model. Between-study heterogeneity was investigated using subgroup analysis and metaregression.

RESULTS

The pooled natural death rate of 1128 per 100 000 person-years exceeded the pooled unnatural deaths of 479 per 100 000 person-year among studies with varying periods of follow-up. Natural deaths significantly exceeded unnatural deaths among studies with a mean follow-up of longer than 2 years, and vascular deaths exceeded suicide deaths among studies with mean period of follow-up of 5 years or longer.

CONCLUSION

Suicide may be the largest single cause of death in the short term after discharge from in-patient psychiatric facilities but vascular disease is the major cause of mortality in the medium- and long-term.

Vitamin D status and correlates of low vitamin D in schizophrenia, other psychoses and non-psychotic depression - The Northern Finland Birth Cohort 1966 study

There is limited knowledge available on the association of vitamin D with psychiatric disorders in young adults. We aimed to investigate vitamin D levels and associating factors in schizophrenia, other psychoses and non-psychotic depression. We studied 4,987 participants from the Northern Finland Birth Cohort 1966 (31 years) with available serum 25-hydroxyvitamin D [25(OH)D] measurements. The final sample was divided into four groups: schizophrenia (n = 40), other psychoses (n = 24), non-psychotic depression (n = 264) and control (n = 4659). To account for the influence of environmental and technical covariates, we generated a vitamin D score variable with correction for season, sex, batch effect and latitude. We further examined how vitamin D levels correlate with anthropometric, lifestyle, socioeconomic and psychiatric measures. Neither serum 25(OH)D concentration nor vitamin D score differed between schizophrenia, other psychoses, non-psychotic depression and control group. The prevalence of vitamin D deficiency was 3.2%, insufficiency 25.5%, and sufficiency 71.3%. Low vitamin D score correlated with regular smoking in the group with schizophrenia. No difference was observed in other psychiatric conditions. We did not find any difference in vitamin D status between schizophrenia, psychoses, non-psychotic depression and control groups, but future studies are warranted to elucidate the role of vitamin D in psychiatric conditions.

Out-of-Hospital Cardiac Arrest in Patients With and Without Psychiatric Disorders: Differences in Use of Coronary Angiography, Coronary Revascularization, and Implantable Cardioverter-Defibrillator and Survival

Background

Healthcare disparities for psychiatric patients are common. Whether these inequalities apply to postresuscitation management in out‐of‐hospital cardiac arrest (OHCA) is unknown. We investigated differences in in‐hospital cardiovascular procedures following OHCA between patients with and without psychiatric disorders.

Methods and Results

Using the Danish nationwide registries, we identified patients admitted to the hospital following OHCA of presumed cardiac cause (2001‐2015). Psychiatric disorders were identified using hospital diagnoses or redeemed prescriptions for psychotropic drugs. We calculated age‐ and sex‐standardized incidence rates and incidence rate ratios (IRRs) of cardiovascular procedures during post‐OHCA admission in patients with and without psychiatric disorders. Differences in 30‐day and 1‐year survival were assessed by multivariable logistic regression in the overall population and among 2‐day survivors who received acute coronary angiography (CAG). We included 7288 hospitalized patients who had experienced an OHCA: 1661 (22.8%) had a psychiatric disorder. Compared with patients without psychiatric disorders, patients with psychiatric disorders had lower standardized incidence rates for acute CAG (≤1 day post‐OHCA) (IRR, 0.51; 95% CI, 0.45–0.57), subacute CAG (2–30 days post‐OHCA) (IRR, 0.40; 95% CI, 0.30–0.52), and implantable cardioverter‐defibrillator implantation (IRR, 0.67; 95% CI, 0.48–0.95). Conversely, we did not detect differences in coronary revascularization among patients undergoing CAG (IRR, 1.11; 95% CI, 0.94–1.30). Patients with psychiatric disorders had lower survival even among 2‐day survivors who received acute CAG: (odds ratio of 30‐day survival, 0.68; 95% CI, 0.52–0.91; and 1‐year survival, 0.66; 95% CI, 0.50–0.88).

Conclusions

Psychiatric patients had a lower probability of receiving post‐OHCA CAG and implantable cardioverter‐defibrillator implantation compared with nonpsychiatric patients but the same probability of coronary revascularization among patients undergoing CAG. However, their survival was lower irrespective of angiographic procedures.

Antipsychotic-induced weight gain and birth weight in psychosis: A fetal programming model

Antipsychotic induced weight gain is a frequent reason for treatment discontinuation in psychosis, subsequently increasing the risk of relapse and negatively affecting patient well-being. The metabolic effect of weight gain and the subsequent risk of obesity constitute a major medical problem on the long term. Despite its consequences, to date few risk factors have been identified (age, gender, body mass index at baseline), with some authors suggesting the implication of early life stressful events, such as perinatal conditions. We aim to describe if a surrogate marker of intrauterine environment (birth weight) might predict weight gain in a cohort of 23 antipsychotic naïve patients at the onset of the psychotic disease evaluated during 16 weeks with olanzapine treatment and in another cohort of 24 psychosis-resistant patients initiating clozapine assessed for 18 weeks. Two independent linear mixed model analyses were performed in each cohort of patients, with prospective weight gain as the dependent variable, age, gender, body mass index, duration of treatment and time as independent variables. Only in naïve patients, weight gain due to antipsychotics was significantly associated with birth weight, while male gender and body mass index at baseline were associated in both cohorts of patients. Treatment-resistant psychotic patients under clozapine were older, had previous antipsychotic treatment and more years of disease, confounders that might have influence a non significant association. Our results suggest that early environmental events might be playing a role in weight evolution in naïve patients treated with antipsychotics.

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

Key Worker-Mediated Enhancement of Physical Health in First Episode Psychosis: Protocol For a Feasibility Study in Primary Care

BACKGROUND

Studies have demonstrated that, for patients with psychosis, a majority of the decline in health status and functioning emerges during the first few years after the onset of illness. This knowledge led to the development of specialized early intervention services (EISs) targeting patients experiencing their first episode of psychosis. The central component of EISs is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users.

OBJECTIVE

This paper outlines the protocol for a feasibility study examining how key workers may enhance physical health by supporting integration between primary and secondary care.

METHODS

Semistructured interviews were conducted with key stakeholder groups (General Practitioners and health care professionals working in mental health services). The interviews informed the development of the complex intervention involving a longitudinal pre-post intervention in 8 general practices in 2 regions in Ireland (one urban and one rural). Patients with first episode psychosis (FEP) will be identified from clinical records at general practices and mental health services.

RESULTS

Baseline and follow-up data (at 6 months) will be collected, examining measures of feasibility, acceptability, and intervention effect size.

CONCLUSIONS

Study findings will inform future practice by examining feasibility of key workers enhancing physical health through improved interaction between primary and secondary care. By identifying issues involved in enhancing recruitment and retention, as well as the likely effect size, the study will inform a future definitive intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13115.

Delay in the Diagnosis of Breast and Colorectal Cancer in People With Severe Mental Disorders

BACKGROUND

People with severe mental disorders have a worse cancer prognosis, with higher mortality rates than the general population, and this could be partially attributed to a later detection. Breast cancer and colorectal cancer have mass population screenings in Spain, but the influence in early diagnosis is unknown in persons with severe mental disorders.

OBJECTIVE

To compare the severity of breast and colorectal cancers at diagnosis in people with and without mental disorders.

METHODS

This was an observational, retrospective, case-control study with 1:2 matching performed in Eastern Spain. Data were retrieved for analysis from electronic medical records.

RESULTS

The study included 111 oncology patients (75 with breast cancer and 36 with colorectal cancer). Individuals with mental disorders had a significantly higher (P = .002) relative risk (odds ratio [OR], 3.93; 95% confidence interval [CI], 1.60-9.65) to be diagnosed with an advanced tumor stage (clinical stages IIIA, IIIB, IIIC, and IV), for both breast and colorectal cancers when analyzed separately. The variables associated with advanced cancer at the time of diagnosis were the presence of a previous mental disorder (OR, 4.67; 95% CI, 1.73-12.61) and older age (OR, 1.08; 95% CI, 1.02-1.14).

CONCLUSIONS

Individuals with severe mental disorders showed a higher risk of being diagnosed with breast and colorectal cancers at advanced stages.

IMPLICATIONS FOR PRACTICE

Cancer screening for earlier detection and intervention in people with severe mental disorders needs improvement. Mental health nurses, screening nurses, and oncology nurses could serve an essential role in increasing the screening adherence of this group of individuals.

Utilization of somatic healthcare in Croatian patients with schizophrenia spectrum disorder, major depression, PTSD and the general population

BACKGROUND

Utilization of somatic healthcare services is highly predictive of the development of chronic physical illnesses and increased mortality risks. The objective of this study was to assess the differences in healthcare utilization among patients with schizophrenia spectrum disorders (SSD), major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and the general population in Croatia.

METHODS

We enrolled 566 Croatian participants from the general population, 282 with SSD, 178 with MDD, and 86 with PTSD. The primary outcome was a self-reported specialist consultation for non-psychiatric (e.g., somatic) causes within the previous 12 months.

RESULTS

Although SSD patients with chronic physical illnesses were significantly more often hospitalized for physical illness than the general population, the proportion of patients who had a specialist consultation were equal in SSD and the general population. MDD and PTSD patients had significantly higher adjusted odds for specialist consultation than the general population and SSD patients (MDD compared to SSD: OR = 2.14; 95% CI 1.27-3.59; PTSD compared to SSD: OR = 2.03; 95% CI 1.00-4.10).

CONCLUSIONS

SSD patients' utilization of somatic healthcare is equal to the general population, despite their increased healthcare needs. However, their utilization is lower than in MDD and PTSD patients and, therefore, probably not adequate.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov ( NCT02773108 ) on May 16, 2016.

Antipsychotic drug use and risk of stroke and myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The effect of antipsychotic (AP) drugs on risk of stroke and myocardial infarction (MI) remains unclear due to methodological limitations of, and inconsistencies across, existing studies. We aimed to systematically review studies reporting on the associations between AP drug use and stroke or MI risk, and to investigate whether associations differed among different sub-populations.

METHODS

We searched Medline, EMBASE, PsychINFO and Cochrane Library (from inception to May 28, 2017) for observational studies reporting on AP drug use and MI or stroke occurrence. We performed random-effects meta-analyses for each outcome, performing sub-groups analyses by study population - specifically general population (i.e. those not restricted to patients with a particular indication for AP drug use), people with dementia only and psychiatric illness only. Where feasible we performed subgroup analyses by AP drug class.

RESULTS

From 7008 articles, we included 29 relevant observational studies, 19 on stroke and 10 on MI. Results of cohort studies that included a general population indicated a more than two-fold increased risk of stroke, albeit with substantial heterogeneity (pooled HR 2.31, 95% CI 1.13, 4.74, I² = 83.2%). However, the risk among patients with dementia was much lower, with no heterogeneity (pooled HR 1.16, 95% CI 1.00, 1.33, I² = 0%) and there was no clear association among studies of psychiatric populations (pooled HR 1.44, 95% CI 0.90, 2.30; substantial heterogeneity [I² = 78.8])). Associations generally persisted when stratifying by AP class, but few studies reported on first generation AP drugs. We found no association between AP drug use and MI risk (pooled HR for cohort studies: 1.29, 95% CI 0.88, 1.90 and case-control studies: 1.07, 95% CI 0.94, 1.23), but substantial methodological and statistical heterogeneity among a relatively small number of studies limits firm conclusions.

CONCLUSIONS

AP drug use may be associated with an increased risk of stroke, but there is no clear evidence that this risk is further elevated in patients with dementia. Further studies are need to clarify the effect of AP drug use on MI and stroke risk in different sub-populations and should control for confounding by indication and stratify by AP drug class.

Adaptation of a sustained care cessation intervention for smokers hospitalized for psychiatric disorders: Study protocol for a randomized controlled trial

BACKGROUND

Individuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25-32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit.

METHODS

A total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge.

CONCLUSION

Results from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.

Mortality and Medical Comorbidity in the Severely Mentally Ill

BACKGROUND

Mentally ill patients die on average 10 years earlier than the general population, largely due to general medical disorders. This study is the first to explore in a large German sample the prevalence, mortality, and medical comorbidity in pa- tients with severe mental illness (SMI). The patients were affected by borderline personality disorder (BPD), psychotic disorders, bipolar disorder, or severe unipolar depression.

METHODS

Our database consists of billing data from all adults with statutory health insurance in Germany. Twelve-month administrative SMI prevalence and medical comorbidity were estimated using cross-sectional data from 2016 (age ≥ 18; N = 59 561 310). Two-year mortality was established longitudinally in a randomly selected subset of the billing data (most recent mortality information available for 2012 to 2014; 2012: n = 15 590 107).

RESULTS

Severe unipolar depression had the highest prevalence (2.01%), followed by psychotic disorders (1.25%), BPD (0.34%), and bipolar disorder (0.29%). While the prevalence of malignant neoplasms showed moderate deviations from reference values [severe unipolar depression: OR = 1.30 (95% CI = 1.29; 1.31), BPD: OR = 1.11 (1.09; 1.14), psychotic dis- orders: OR = 0.90 (0.89; 0.90), bipolar disorder: OR = 1.07 (1.06; 1.09)], other disease groups (infectious, endocrine/nutritional/ metabolic, circulatory, respiratory) were substantially elevated in all categories of SMI. Mortality rates for psychotic disorders, BPD, bipolar disorder, and severe unipolar depression were increased (OR = 2.38 [95% CI=2.32; 2.44], 2.30 [2.08; 2.54], 1.52 [1.42; 1.62], and 1.40 [1.37; 1.44], respectively), with a loss of 2.6 to 12.3 years, depending on age, sex, and SMI.

CONCLUSION

Mortality is substantially elevated in all SMI patients. The results underline the need to remove barriers to adequate general medical care, both on the patient and the provider side, to reduce excess mortality.

Mental-Physical Multimorbidity in Youth: Associations with Individual, Family, and Health Service Use Outcomes

Prevalence, correlates, and outcomes of youth with comorbid mental and physical conditions (i.e., multimorbidity) were examined in this cross-sectional study. Participants were 92 youth (14.5 years [SD 2.7]; 69.6% female) and their parents. Mental disorder was assessed using structured interviews and physical health using a standardized questionnaire. Twenty-five percent of youth had multimorbidity and no child or parent demographic or health characteristics were correlated with multimorbidity. Youth with multimorbidity reported similar quality of life and better family functioning [B = - 4.80 (- 8.77, - 0.83)] compared to youth with mental disorder only (i.e., non-multimorbid). Youth with multimorbidity had lower odds of receiving inpatient services [OR = 0.20 (0.05, 0.85)] and shorter stays in hospital for their mental health [OR = 0.74 (0.57, 0.91)] over the past year. Family functioning was found to mediate the association between youth multimorbidity and length of stay [αβ = 0.14 (0.01, 0.27)]. Findings reinforce the need for family-centered youth mental health care.

Exploring opportunities to support mental health care using social media: A survey of social media users with mental illness

AIM

Social media holds promise for expanding the reach of mental health services, especially for young people who frequently use these popular platforms. We surveyed social media users who self-identified as having a mental illness to learn about their use of social media for mental health and to identify opportunities to augment existing mental health services.

METHODS

We asked 240 Twitter users who self-identified in their profile as having a mental illness to participate in an online survey. The survey was in English and inquired about participants' mental health condition, use of social media for mental health and interest in accessing mental health programs delivered through social media.

RESULTS

Respondents from 10 countries completed 135 surveys. Most respondents were from the United States (54%), Canada (22%) and the United Kingdom (17%) and reported a psychiatric diagnosis of either schizophrenia spectrum disorder (27%), bipolar disorder (25%), major depressive disorder (16%) or depression (20%). Young adults age ≤35 (46%) were more likely to use Instagram (P = .002), Snapchat (P < .001) and their mobile phone for accessing social media (P < .001) compared to adults age 36 and older (53%). Most participants (85%) expressed interest in mental health programs delivered through social media, especially to promote overall health and wellbeing (72%) and for coping with mental health symptoms (90%).

CONCLUSIONS

This exploratory study demonstrates the feasibility of reaching social media users with mental illness and can inform efforts to leverage social media to make evidence-based mental health services more widely available to those in need.

Undiagnosed cardiovascular disease prior to cardiovascular death in individuals with severe mental illness

OBJECTIVE

To examine whether individuals with schizophrenia (SCZ) or bipolar disorder (BD) had equal likelihood of not being diagnosed with cardiovascular disease (CVD) prior to cardiovascular death, compared to individuals without SCZ or BD.

METHODS

Multivariate logistic regression analysis including nationwide data of 72 451 cardiovascular deaths in the years 2011-2016. Of these, 814 had a SCZ diagnosis and 673 a BD diagnosis in primary or specialist health care.

RESULTS

Individuals with SCZ were 66% more likely (OR: 1.66; 95% CI: 1.39-1.98), women with BD were 38% more likely (adjusted OR: 1.38; 95% CI: 1.04-1.82), and men with BD were equally likely (OR: 0.88, 95% CI: 0.63-1.24) not to be diagnosed with CVD prior to cardiovascular death, compared to individuals without SMI. Almost all (98%) individuals with SMI and undiagnosed CVD had visited primary or specialized somatic health care prior to death, compared to 88% among the other individuals who died of CVD.

CONCLUSION

Individuals with SCZ and women with BD are more likely to die due to undiagnosed CVD, despite increased risk of CVD and many contacts with primary and specialized somatic care. Strengthened efforts to prevent, recognize, and treat CVD in individuals with SMI from young age are needed.

What is the prevalence, and what are the clinical correlates, of insulin resistance in young people presenting for mental health care? A cross-sectional study

OBJECTIVES

To report the distribution and predictors of insulin resistance (IR) in young people presenting to primary care-based mental health services.

DESIGN

Cross-sectional.

SETTING

Headspace-linked clinics operated by the Brain and Mind Centre of the University of Sydney.

PARTICIPANTS

768 young people (66% female, mean age 19.7±3.5, range 12-30 years).

MAIN OUTCOME MEASURES

IR was estimated using the updated homeostatic model assessment (HOMA2-IR). Height and weight were collected from direct measurement or self-report for body mass index (BMI).

RESULTS

For BMI, 20.6% of the cohort were overweight and 10.2% were obese. However, <1% had an abnormally high fasting blood glucose (>6.9 mmol/L). By contrast, 9.9% had a HOMA2-IR score >2.0 (suggesting development of IR) and 11.7% (n=90) had a score between 1.5 and 2. Further, there was a positive correlation between BMI and HOMA2-IR (r=0.44, p<0.001). Participants in the upper third of HOMA2-IR scores are characterised by younger age, higher BMIs and depression as a primary diagnosis. HOMA2-IR was predicted by younger age (β=0.19, p<0.001) and higher BMI (β=0.49, p<0.001), together explaining 22% of the variance (F_(2,361)=52.1, p<0.001).

CONCLUSIONS

Emerging IR is evident in a significant subgroup of young people presenting to primary care-based mental health services. While the major modifiable risk factor is BMI, a large proportion of the variance is not accounted for by other demographic, clinical or treatment factors. Given the early emergence of IR, secondary prevention interventions may need to commence prior to the development of full-threshold or major mood or psychotic disorders.

Maintenance treatment for patients with a first psychotic episode

PURPOSE OF REVIEW

To provide an update of recent studies relevant for maintenance treatment with antipsychotic medication after a first psychotic episode (FEP).

RECENT FINDINGS

Despite controversy derived from a follow-up analysis from an earlier study showing that attempted early discontinuation after remission was associated with improved long-term functioning, most other studies support better long-term outcome with continuous maintenance treatment after the first episode. However, the main question is not whether, but for how long maintenance treatment after FEP should be offered. Consistent evidence shows that withdrawal from antipsychotics increases the risk for a relapse or re-hospitalization. On the other hand, maintenance treatment is associated with the risk to develop burdensome antipsychotic-induced side-effects and one should keep in mind that around 20% of FEP will not have a second episode. In this regard, the decision for maintenance treatment for periods above some months must be the result of a comprehensive risk-benefit evaluation during a shared decision-making process.

SUMMARY

There is no replicated evidence that prognosis can be improved by discontinuing antipsychotic medication after a FEP. There is a clear need for additional studies to develop single-subject outcome predictors and to identify long-term efficacy of maintenance treatment beyond relapse (e.g. recovery).

The impact of depression on adherence to organized and opportunistic breast cancer screening

One in five women will experience depression over her lifetime, and one out of eight will develop breast cancer. We evaluated the effect of depression on adherence to mammography in Switzerland, where opportunistic and organized screening programs coexist. We analyzed data from 3206 women aged 50-69 who participated in the Swiss Health Survey 2012. We compared mammographic rates among women with no to mild versus moderate to severe depressive symptoms. The effect of the type of screening on the odds of undertaking a mammography was calculated using multivariable logistic regression analysis. Women with moderate to severe major depressive symptoms were more likely to have had a mammography in the previous 2 years than their nondepressed or less-depressed counterparts (51 vs. 39.2%, respectively, P = 0.005). In the multivariable analysis, women with no to mild major depression living in cantons with an organized screening program had an adjusted odds ratio of 2.7 (95% confidence interval: 2.30-3.17, P < 0.001) of having had a mammography within the past 24 months compared with those living in the regions with an opportunistic screening. The adjusted odds ratio for women with moderate to severe major depression was 4.21 (95% confidence interval: 2.13-8.33, P < 0.001). In Switzerland. adherence to mammographic screening among women with moderate to severe major depression is higher than among women with no or minimal major depressive symptoms. This increased adherence is even more pronounced in regions with organized screening.

Cardiovascular risk remains high in schizophrenia with modest improvements in bipolar disorder during past decade

OBJECTIVE

While CVD risk has decreased in the general population during the last decade, the situation in patients with schizophrenia (SCZ) and bipolar disorder (BD) is unknown.

METHODS

We compared CVD risk factors in patients with SCZ and BD recruited from 2002-2005 (2005 sample, N = 270) with patients recruited from 2006-2017 (2017 sample, N = 1011) from the same catchment area in Norway. The 2017 sample was also compared with healthy controls (N = 922) and the general population (N range = 1285-4587, Statistics Norway) from the same area and period.

RESULTS

Patients with SCZ and BD in the 2017 sample had significantly higher level of most CVD risk factors compared to healthy controls and the general population. There was no significant difference in the prevalence of CVD risk factors in SCZ between the 2005 and 2017 samples except a small increase in glucose in the 2017 sample. There were small-to-moderate reductions in hypertension, obesity, total cholesterol, low-density lipoprotein, systolic and diastolic blood pressure in the BD 2017 sample compared to the 2005 sample.

CONCLUSION

Despite major advances in health promotion during the past decade, there has been no reduction in the level of CVD risk factors in patients with SCZ and modest improvement in BD.

Physical health status of older adults with severe mental illness: The PHiSMI-E cohort study

The objective was to use various somatic parameters as basis for investigating the physical health of older adults with severe mental illnesses (SMI). A cross-sectional study design is performed by using baseline data from the Physical Health in SMI-elderly (PHiSMI-E) study. Data were collected using the Nursing Monitoring of Somatic Status and Lifestyle - Mental Health instrument in adults aged over 60 with SMI in a large Dutch mental health institute. Ninety-nine elderly SMI patients were included. Somatic comorbidity (84.8%), use of somatic medication (77.7%) and polypharmacy (67.7%) were prevalent. Extrapyramidal symptoms were experienced by 51% of patients, mainly in the subgroup with psychotic disorders (75.6%). Unhealthy diet was reported in 16.2%, obesity in 27.3%, and physical inactivity in 57.6%. Fatigue (67.7%) and dry mouth (66.6%) were the commonest reported physical symptoms. Mean VAS score (scale 0-10) indicating participants' self-perceived physical health was 6.7 (SD ± 1.6). After division of the total patient group into tertiles based on the VAS scores, the lowest tertile was characterized by less physical activity, unhealthier diet, more use of medication, more fatigue, somnolence, and inner agitation. In conclusion, impaired physical health status was common in these older patients with SMI. Although they had more psychiatric and somatic comorbidity than adult SMI patients described in the literature, they had a healthier lifestyle. To reduce morbidity and premature mortality in these frail patients, it is essential that healthcare providers are aware of the high prevalence of somatic comorbidity and symptoms, and of their interactions with the psychiatric disorders. This study improves our understanding of differences in vulnerability factors of older patients with SMI. The (early) detection of somatic comorbidities may improve long-term health outcomes of these patients.

Disagreement between service-users and clinicians assessment of physical health during early psychosis

AIMS

Physical illnesses account for the majority of excess deaths following psychosis; access to care and treatment is inequitable and schizophrenia has now been dubbed the life-shortening disease. We compared service-users and clinician's perspectives of their physical health assuming that one of the fundamental issues in prompting screening and treatment is the view that health is poor.

METHODS

Data comprising sample characteristics, diagnosis, symptoms, insight, antecedents to psychosis and physical health perspectives were obtained prospectively as part of a larger epidemiological study of first-episode psychosis. We compared physical health perspectives between service-users and clinicians and examined clinical correlates.

RESULTS

Contrary to our expectations, we found that service-users reported poorer physical health over time than clinicians did.

CONCLUSION

Reconciling service-users and clinician's views of physical health may be an important step towards collaborative care and improving access to better quality healthcare for serious mental illness.

Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study

AIMS

A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care.

METHODS

This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge.

RESULTS

There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26-1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68-2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40-0.53)).

CONCLUSION

Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.

Clozapine and Long-Term Mortality Risk in Patients With Schizophrenia: A Systematic Review and Meta-analysis of Studies Lasting 1.1-12.5 Years

INTRODUCTION

Patients with schizophrenia have an elevated mortality risk compared to the general population, with cardiovascular-related deaths being the leading cause. The role of clozapine use in the long-term mortality risk is unclear. While clozapine treatment may increase the risk for cardiovascular mortality, it may have protective effects regarding suicidal behavior.

METHODS

We systematically searched EMBASE, MEDLINE, and PsycINFO and reviewed studies that used a long-term follow-up (ie, >52 weeks) and reported on mortality in adults diagnosed with schizophrenia-spectrum disorders who had received clozapine treatment.

RESULTS

Altogether, 24 studies reported on 1327 deaths from any causes during 217691 patient years in patients treated with clozapine. The unadjusted mortality rate in 22 unique samples during a follow-up of 1.1-12.5 (median = 5.4) years was 6.7 (95% confidence interval [CI] = 5.4-7.9) per 1000 patient years. Long-term, crude mortality rate ratios were not significantly lower in patients ever treated with clozapine during follow-up, but significantly lower in patients continuously treated with clozapine compared to patients with other antipsychotics (mortality rate ratio = 0.56, 95% CI = 0.36-0.85, P-value = .007). Few studies reported on rates of long-term cause-specific mortality (suicide and ischemic heart disease), which showed no significant difference in patients using clozapine compared to patients using other antipsychotics. Statistical heterogeneity was high in all analyses.

DISCUSSION

Continuous clozapine treatment in schizophrenia patients was associated with a significantly lower long-term all-cause mortality rate compared to other antipsychotic use. These findings, combined with the known efficacy of clozapine, give reason to re-evaluate the hesitancy to prescribe clozapine in regular care settings.

TRIAL REGISTRATION

PROSPERO CRD42017069390.

A longitudinal study of healthcare utilisation and expenditure in people with type 2 diabetes mellitus with and without major depressive disorder

OBJECTIVE

This study investigated the healthcare service utilisation and expenditure of patients with type 2 diabetes mellitus (T2DM) and major depressive disorder (MDD) and identified associated factors.

METHODS

Healthcare service utilisation and expenditure of patients with T2DM with and without MDD during 2002-2013 were examined using Taiwan's population-based National Health Insurance claims database. Healthcare service utilisation included outpatient visits and inpatient admissions, and health expenditure included outpatient, inpatient, and total medical expenditure. Moreover, non-psychiatric health service utilisation and expenditure were distinguished from total health service utilisation and medical expenditure.

RESULTS

Average healthcare service utilisation was significantly higher in those with comorbid MDD (both total and non-psychiatric utilisation). The higher overall costs of the patients with comorbid MDD largely driven by psychiatric costs and non-psychiatric costs between the groups were not significantly different. Gender, age, income, comorbidities and complications, and diabetes complications severity index were significant factors in outpatient visits, medical expenditure, and hospitalisation in those with comorbid MDD.

CONCLUSIONS

Type 2 diabetes patients with comorbid MDD were found to have higher costs, and that they appeared to be driven by more visits in the first 6 years and by psychiatric-related costs rather than general medical costs.

Design and methods of the 'monitoring outcomes of psychiatric pharmacotherapy' (MOPHAR) monitoring program - a study protocol

Background

At many outpatient departments for psychiatry worldwide, standardized monitoring of the safety of prescribed psychotropic drugs is not routinely performed in daily clinical practice. Therefore it is unclear to which extent the drugs used by psychiatric outpatients are prescribed effectively and safely. These issues warrant structured monitoring of medication use, (pre-existing) co-morbidities, effectiveness and side effects during psychiatric outpatient treatment. Improvement of monitoring practices provides an opportunity to ensure that somatic complications and adverse drug effects are detected and dealt with in a timely manner. Structural support for data collection and follow-up tests seems essential for improvement of monitoring practices in psychiatric outpatients. The implementation of a structured somatic monitoring program as part of routine clinical practice, as we describe in this study protocol, may be a solution.

Methods

In order to address these issues, we developed the innovative program ‘Monitoring Outcomes of Psychiatric Pharmacotherapy (MOPHAR)’. MOPHAR is an infrastructure for implementation of standardized routine outcome monitoring (ROM; including standardized monitoring of treatment effect), monitoring of adverse psychotropic medication effects in psychiatric outpatients, encompassing both somatic adverse effects (e.g. metabolic disturbances) and subjective adverse effects (e.g. sedation or sexual side effects) and medication reconciliation.

Discussion

In the MOPHAR monitoring program, a nurse performs general and psychotropic drug-specific somatic screenings and provides the treating mental health care providers with more and better information on somatic monitoring for treatment decisions. Given our experience regarding implementation of the MOPHAR program, we expect that the MOPHAR program is feasible and beneficial for patients in any MHS organisation. This paper describes the objectives, target population, setting and the composition and roles of the treatment team. It also indicates what measurements are performed at which time points during outpatient treatment in the MOPHAR monitoring program, as well as the research aspects of this project.

Trial registration

MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014. (NL4779).

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3951-2) contains supplementary material, which is available to authorized users.

Impact of preexisting mental illness on breast cancer endocrine therapy adherence

PURPOSE

Patients with estrogen receptor positive (ER+) breast cancer are often non-adherent to endocrine therapies, despite clear survival benefits. We utilized a nationally representative cancer cohort to examine the role of specific mental illnesses on endocrine therapy adherence.

METHODS

Using the SEER-Medicare database, we included 21,894 women aged 68+ at their first surgically treated stage I-IV ER+ breast cancer during 2007-2013. All had continuous fee-for-service Medicare Parts A and B for 36+ months before, 18+ months after diagnosis, and continuous Part D for 4+ months before, 18+ after diagnosis. Mental illness was defined as occurring in the 36 months prior to cancer onset. We analyzed endocrine therapy adherence, initiation, and discontinuation using longitudinal linear and Cox regression models.

RESULTS

Unipolar depression (11.0%), anxiety (9.5%), non-schizophrenia psychosis (4.6%), and dementias (4.6%) were the most prevalent diagnoses. Endocrine therapies were initiated by 80.0% of women. Among those with at least one year of use, 28.0% were non-adherent (< 0.80 adherence, mean = 0.84) and 25.7% discontinued. Patients with dementia or bipolar depression/psychotic/schizophrenia disorders had lower adjusted initiation probabilities by year one of follow-up, versus those without these diagnoses [0.74 95% CI (0.73-0.74) and 0.73 (0.72-0.73), respectively, reference 0.76 (0.76-0.77)]. Patients with substance use or anxiety disorders less frequently continued endocrine therapy for at least one year, after adjustment, [0.85 95% CI (0.85-0.86) and 0.88 (0.87-0.88), respectively, reference 0.90 (0.89-0.90)]. Patients with substance use disorders had 2.3% lower adherence rates (p < 0.001).

CONCLUSIONS

Nearly one-quarter of female Medicare beneficiaries have diagnosed mental illness preceding invasive breast cancer. Those with certain mental illnesses have modestly reduced rates of initiation, adherence, and discontinuation and this may help define patients at higher risk of treatment abandonment. Overall, endocrine therapy adherence remains suboptimal, unnecessarily worsening recurrence and mortality risk.

Patient perspectives on how living with a mental illness affects making and maintaining healthy lifestyle changes

OBJECTIVE

To understand the ways that mental health symptoms interfere with achieving health goals.

METHODS

Individuals with mental illness diagnoses and varying levels of preventive service use were recruited from federally qualified health centers and an integrated health care delivery system and interviewed. Thematic analysis was used to characterize descriptions of how mental illness experiences influenced lifestyle change efforts.

RESULTS

Three themes described patients' (n = 163) perspectives on barriers to making healthy lifestyle changes: 1) Thinking about making lifestyle changes is overwhelming for individuals already managing the burdens of mental illnesses; 2) Depression makes it difficult to care about a healthy future; and 3) When mental illness symptoms are not adequately treated unhealthy behaviors that provide relief are unlikely to be discontinued. Participants also made suggestions for improving health care delivery to facilitate positive behavior change.

CONCLUSION

Patients with mental illnesses need their clinicians to be empathic, help them envision a healthier future, address unmet mental health needs, and provide resources.

PRACTICE IMPLICATIONS

Primary care clinicians should encourage their patients with mental illnesses to make healthy lifestyle changes within the context of a supportive relationship. Lifestyle change can be overwhelming; clinicians should acknowledge progress and provide ongoing tangible support.

Metabolic abnormalities and low dietary Omega 3 are associated with symptom severity and worse functioning prior to the onset of psychosis: Findings from the North American Prodrome Longitudinal Studies Consortium

OBJECTIVE

Patients with schizophrenia have a high prevalence of metabolic disorders and cardiovascular mortality. It is possible that a vulnerability to metabolic abnormalities is associated with risk for psychosis, symptoms and functionality. In this study, we evaluate demographic information, cardiometabolic indices, symptoms and functioning in an antipsychotic free cohort at Clinical High Risk (CHR) for psychosis from the NAPLS Omega 3 fatty acid clinical trial.

METHOD

Subjects received physical exams and metabolic monitoring prior to randomization into the Omega 3 versus Placebo trial. Anthropometrical measures, vital signs, glucose, and lipids were assessed along with symptoms, functioning, dietary Omega 3 fatty acids, erythrocyte polyunsaturated fatty acid content and a measure of lipid peroxidation (TBARS, Thiobarbituric acid-reactive substances).

RESULTS

The sample included 113 CHR subjects (42.1% female; 17.5% Latino) ages 12-29. The mean BMI was 24.3 with a trend toward higher BMI and a higher incidence of metabolic syndrome in Latino subjects; 36% of the sample was obese/overweight; 37.6% met criteria for prehypertension/hypertension; 4.2% met criteria for prediabetes/diabetes; 9.6% showed evidence of insulin resistance and 44.7% had dyslipidemia. The TBARS was elevated at 9.8 μM ± 6.1 (normal 1.86-3.94 μM). Metabolic parameters and a diet low in Omega 3 rich foods were significantly associated with prodromal symptoms and poor functioning.

CONCLUSIONS

CHR subjects show a high percentage of metabolic abnormalities prior to exposure to antipsychotic medication. These findings reinforce that early detection of metabolic disturbances and food insecurity is crucial since these factors are modifiable with the potential for significant gains in terms of quality of life, physical and mental health.

The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of randomized controlled trials

We summarized and compared meta-analyses of pharmacological and non-pharmacological interventions targeting physical health outcomes among people with schizophrenia spectrum disorders. Major databases were searched until June 1, 2018. Of 3,709 search engine hits, 27 meta-analyses were included, representing 128 meta-analyzed trials and 47,231 study participants. While meta-analyses were generally of adequate or high quality, meta-analyzed studies were less so. The most effective weight reduction interventions were individual lifestyle counseling (standardized mean difference, SMD=-0.98) and exercise interventions (SMD=-0.96), followed by psychoeducation (SMD=-0.77), aripiprazole augmentation (SMD=-0.73), topiramate (SMD=-0.72), d-fenfluramine (SMD=-0.54) and metformin (SMD=-0.53). Regarding waist circumference reduction, aripiprazole augmentation (SMD=-1.10) and topiramate (SMD=-0.69) demonstrated the best evidence, followed by dietary interventions (SMD=-0.39). Dietary interventions were the only to significantly improve (diastolic) blood pressure (SMD=-0.39). Switching from olanzapine to quetiapine or aripiprazole (SMD=-0.71) and metformin (SMD=-0.65) demonstrated best efficacy for reducing glucose levels, followed by glucagon-like peptide-1 receptor agonists (SMD=-0.39), dietary interventions (SMD=-0.37) and aripiprazole augmentation (SMD=-0.34), whereas insulin resistance improved the most with metformin (SMD=-0.75) and rosiglitazone (SMD=-0.44). Topiramate had the greatest efficacy for triglycerides (SMD=-0.68) and low-density lipoprotein (LDL)-cholesterol (SMD=-0.80), whereas metformin had the greatest beneficial effects on total cholesterol (SMD=-0.51) and high-density lipoprotein (HDL)-cholesterol (SMD=0.45). Lifestyle interventions yielded small effects for triglycerides, total cholesterol and LDL-cholesterol (SMD=-0.35 to -0.37). Only exercise interventions increased exercise capacity (SMD=1.81). Despite frequent physical comorbidities and premature mortality mainly due to these increased physical health risks, the current evidence for pharmacological and non-pharmacological interventions in people with schizophrenia to prevent and treat these conditions is still limited and more larger trials are urgently needed.

The medical home functions of primary care practices that care for adults with psychological distress: a cross-sectional study

BACKGROUND

Primary care practices are changing the way that they provide care by increasing their medical home functionality. Medical home functionality can improve access to care and increase patient-centeredness, which is essential for persons with mental health issues. This study aims to explore the degree to which medical home functions have been implemented by primary care practices that care for adults with psychological distress.

METHODS

Analysis of the 2015 Medical Expenditure Panel Survey Household Component and Medical Organizations Survey. This unique data set links data from a nationally representative sample of US households to the practices in which they receive primary care. This study focused on adults aged 18 and above.

RESULTS

As compared to adults without psychological distress, adults with psychological distress had significantly higher rates of chronic illness and poverty. Adults with psychological distress were more likely to receive care from practices that include advanced practitioners and are non-profit or hospital-based. Multivariate models that were adjusted for patient-level and practice-level characteristics indicated that adults with psychological distress are as likely to receive primary care from practices with medical home functionality, including case management, electronic health records, flexible scheduling, and PCMH certification, as adults without psychological distress.

CONCLUSIONS

Practices that care for adults with mental health issues have not been left behind in the transition towards medical home models of primary care. Policy makers should continue to prioritize adults with mental health issues to receive primary care through this model of delivery due to this population's great potential to benefit from improved access and care coordination.

TRIAL REGISTRATION

This study does not report the results of a health care intervention on human subject's participants.

Psychological Distress and Access to Care Among Midlife Women

Objective: The objective of this study is to examine unmet health care needs among midlife women (ages 50-64 years) in the United States by level of psychological distress. Method: Using data for a nationally representative sample of midlife women (N = 8,838) from the 2015-2016 National Health Interview Survey, we estimated odds ratios of reasons for delayed care and types of care foregone by level of psychological distress-none, moderate (moderate psychological distress [MPD], and severe (severe psychological distress [SPD]). Findings: More than one in five midlife women had MPD (15.3%) or SPD (5.2%). Women with MPD or SPD had 2 to 5 times higher odds of delayed and 2 to 20 times higher odds of foregone care. Conclusions: Midlife women with psychological distress have poorer health than those with no distress, yet they are less likely to get needed health care. There is a missed window of opportunity to address mental health needs and manage comorbid chronic conditions to facilitate healthy aging.

The Role of Proopiomelanocortin and α-Melanocyte-Stimulating Hormone in the Metabolic Syndrome in Psychiatric Disorders: A Narrative Mini-Review

The metabolic syndrome (MetS) comprises abdominal obesity, preclinical or full diabetes type 2, arterial hypertension, and dyslipidemia and affects a significant proportion of the general population with a remarkably higher prevalence in patients suffering from psychiatric disorders. However, studies exploring the pathogenetic link between MetS and psychiatric diseases are rare. Here, we aim to narrow this gap in knowledge by providing a narrative review on this topic that focuses on two psychiatric diseases, namely on schizophrenia and posttraumatic stress disorder (PTSD) since we assume them to be associated with two different main causalities of MetS: in schizophrenia, MetS evidently develops or aggravates in response to antipsychotic drug treatment while it assumingly develops in response to stress-induced endocrine and/or epigenetic alterations in PTSD. First, we compared the prevalences of MetS and associated pathologies (which we took from the latest meta-analyses) among different psychiatric disorders and were surprised that the prevalences of arterial hypertension and hyperglycemia in PTSD almost doubles those of the other psychiatric disorders. Next, we performed a literature search on the neurobiology of MetS and found numerous articles describing a role for proopiomelanocortin (POMC) in MetS. Thus, we concentrated further analysis on POMC and one of its downstream effector hormones, α-melanocyte-stimulating hormone (α-MSH). We found some evidence for a role of POMC in both PTSD and schizophrenia, in particular in antipsychotic-induced MetS, as well as for α-MSH in schizophrenia, but, surprisingly, no study on α-MSH in PTSD. Taken together, our synopsis reveals, first, a potential interaction between the POMC system and stress in the assumingly at least partially shared pathogenesis of psychiatric disorders and MetS, second, that modulation of the POMC system, in particular of the melanocortin 3 and 4 receptors, might be a promising target for the treatment of MetS and, third, that the DNA methylation status of POMC might speculatively be a promising biomarker for MetS in general and, possibly, in particular in the context of stress-related psychiatric conditions such as PTSD. To best of our knowledge, this is the first review on the role of the POMC system in MetS in psychiatric disorders.

Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders

PURPOSE

Excessive mortality has been seen in patients with personality disorder (PD), but it has not been well-studied when patients also have other psychiatric comorbidities. This study investigated the mortality rates and causes of death in an Asian cohort with PD.

METHOD

We enrolled patients ≥ 18 years of age with PD as defined by DSM-IV criteria (N = 1172), who had been admitted to a psychiatric service center in northern Taiwan between 1985 and 2008. By linking with the national mortality database (1985-2008), cases of mortality (n = 156, 13.3%) were obtained. We calculated the standardized mortality ratios (SMRs) to estimate the mortality gap between patients with PD and the general population. Stratified analyses of mortality rates by Axis I psychiatric comorbidity and sex were performed.

RESULTS

Borderline PD (n = 391, 33.4%) was the dominant disorder among the subjects. The SMRs for all-cause mortality of PD alone, PD comorbid with non-substance use disorder(non-SUD), and PD comorbid with SUD were 4.46 (95% CI 1.94-6.98), 7.42 (5.99-8.85), and 15.96 (11.07-20.85), respectively. Among the causes of death, the SMR for suicide was the highest (46.92, 95% CI 34.29-59.56). The SMR for suicide in PD patients with comorbid SUD was unusually high (74.23, 95% CI 33.88-114.58). Women had a significant increase in suicide with an SMR of 59.00 (95% CI 37.89-80.11). Men had significant increase in SMRs for cardiovascular disease and gastrointestinal disease.

CONCLUSIONS

We found significant synergistic effects of PD and SUD on mortality risk. A personality assessment should be mandatory in all clinical settings to prevent premature death and detect SUD early.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Inhibited autonomy for promoting physical health: qualitative analysis of narratives from persons living with severe mental illness

BACKGROUND

Autonomy is a key factor in the reduction of inequitable physical healthcare among people with severe mental illness compared with the general population.AimsTo clarify the critical mechanism underlying autonomy in physical health promotion based on the perspectives of people with severe mental illness.

METHOD

We employed a conventional content analysis of narrative data from the Healthy Active Lives in Japan (HeAL Japan) workshop meetings.

RESULTS

'Inhibited autonomy' was extracted as a central component and shaped by the users' experiences, both in a healthcare setting and in real life. This component emerged based on the lack of an empowerment mechanism in psychiatric services.

CONCLUSIONS

A barrier to the encouragement of autonomy in physical health promotion was found in current psychiatric services. An effective strategy should be explored to foster an empowerment mechanism in psychiatric and mental health services.Declaration of interestNone.

Association between hyperuricemia and metabolic syndrome in patients suffering from bipolar disorder

BACKGROUND

Clinical studies have shown that bipolar patients have increased serum uric acid levels. High serum uric acid levels could play a role contributing to high prevalence of metabolic syndrome. Metabolic syndrome is known to increase the risk of developing a number of life threatening diseases including coronary heart disease, hypertension, and type 2 diabetes. This study investigated the association between hyperuricemia and metabolic syndrome and its components in individuals suffering from bipolar disorders.

METHODS

This study recruited 318 inpatients suffering from bipolar disorders from Beijing Hui-Long-Guan Hospital in China and 160 healthy subjects from the same region as the controls. We used National Cholesterol Education Program Adult Treatment Panel III Adapted criteria (NCEP ATP-III A) for the diagnosis of metabolic syndrome. Hyperuricemia was determined as serum uric acid level above 420 μmol/L in men and 360 μmol/L in women (N Engl J Med 359(17):1811-1821, 2008).

RESULTS

Among 318 bipolar patients, there was higher prevalence of metabolic syndrome (42.5%) and hyperuricemia (27.7%) than healthy controls (21.9 and 11.9%). Bipolar patients with metabolic syndrome had increased prevalence of hyperuricemia (OR = 3.0, CI95 [1.7-5.4]). Hypertriglyceridemia and larger waist circumference (WC) were associated with hyperunicemia (OR = 1.8, CI95 [1.1-3.1], OR = 1.9, CI95 [1.1-3.4]). Hyperuricemia was associated with metabolic syndrome in bipolar patients (p < 0.001) and especially with hypertriglyceridemia (OR = 1.9, CI95 [1.1-3.1] and increased WC (OR = 2.1 [1.2-4.0]). Bipolar patients over 50 years of age and hyperuricemia were highly prone to develop metabolic syndrome (OR = 14.0, CI95 [5.0-39.0]).

CONCLUSIONS

Hyperuricemia was highly associated with development of metabolic disorder particularly for aged patients suffering from bipolar disorders. Early prevention of hyperuricemia and metabolic syndrome may lead better life for bipolar patients when they get older.

Mortality Rates and Trends Among Bologna Community Mental Health Service Users: A 13-Year Cohort Study

The present study aimed to determine mortality rates and trends among community mental health service users in Bologna (Italy) between 2001 and 2013. Standardized mortality ratios (SMRs) were calculated, and Poisson multiple regression analysis was performed. The cohort comprised 42,357 patients, of which 3556 died. The overall SMR was 1.62 (95% confidence interval = 1.57-1.67). SMRs for natural causes of death ranged from 1.25 to 2.30, whereas the SMR for violent deaths was 3.45. Both serious and common mental disorders showed a significant excess of mortality, although higher rates were found in severe mental disorders, especially in personality disorders. Different from most published studies, the overall SMR slightly decreased during the study period. The present study, though confirming that people with mental disorders present a higher risk of mortality, calls for prevention strategies oriented to all psychiatric diagnoses.

Colocating an accredited practising dietitian to an adult community mental health service: An exploratory study

For people with severe mental illness, accredited practising dietitians may assist with a nutrition care plan that considers the medical, psychiatric, psychological, social, spiritual, and pharmacological aspects of their care. However, consumers' access to care has been limited by difficulties attending appointments and suboptimal interface between nutritional and mental health services. Therefore, the objectives of this exploratory study were to describe access to, and key stakeholder perspectives of, the accredited practising dietitian role colocated in a community mental health service. A total of 16 key stakeholders participated in one-to-one interviews. Two main themes with subthemes were derived from analysis of interviews: (i) 'building empowerment and collaboration' and included the subthemes, (a) nutrition awareness and education and (b) healthy lifestyle changes, and (ii) 'overcoming challenges to optimal nutrition and effective health care'. In addition, improved access to the role was demonstrated with 124 (79%) consumers attending at least one appointment with an accredited practising dietitian. A total of 15 (12%) consumers attended more than 10 appointments during their outpatient admission to the community mental health service. Colocating an accredited practising dietitian was perceived to build empowerment and collaboration, and overcome challenges to optimal nutrition and effective health care for consumers, carers, and clinicians. The colocation of a dietitian can empower consumers' to make health-informed decisions and support their willingness to engage with physical healthcare provision when it is prioritized alongside mental healthcare provision.

Utilization of somatic specialist services among psychiatric immigrant patients: the Norwegian patient registry study

Background

Amongst psychiatric patients, the leading causes of reduced quality of life and premature death are chronic viral infections and cardiovascular diseases. In spite of this, there are extremely high levels of disparity in somatic healthcare amongst such populations. Little research has explored patterns of healthcare utilisation and, therefore, this study aims to examine the use of somatic specialist healthcare for infectious diseases and diseases of circulatory system among psychiatric patients from different immigrant groups and ethnic Norwegians.

Methods

Register data from the Norwegian Patient Registry and Statistics Norway were used. The sample (ages 0–90+) consisted of 276,890 native-born Norwegians and 52,473 immigrants from five world regions – Western countries, East Europe, Africa, Asia, and Latin America, all of whom had contacts with specialist mental healthcare during the period 2008–2011. Statistical analyses were applied using logistic regression models.

Results

Rates of outpatient consultation for circulatory system diseases were significantly lower amongst patients from Africa, Asia and Latin America compared with ethnic Norwegian psychiatric patients. Only patients from Eastern Europeans had a higher rate. With regard to hospital admission, all psychiatric patients had a lower rate than ethnic Norwegians with the exception of those from Africa where the finding was non-significant. In terms of infectious diseases, patients from African countries had significantly higher outpatient and admission rates than ethnic Norwegians. Outpatient consultation rates were lower amongst those from Western and Latin America and hospital admission rates were lower amongst those from Eastern Europe and Asia.

Conclusions

The findings suggest that the majority of immigrant psychiatric patients have lower hospitalization rates for circulatory system diseases than Norwegian psychiatric patients. This may suggest that poor access for immigrants is a contributing factor, though the findings were less pronounced for infectious diseases.

Patterns of chronic physical multimorbidity in psychiatric and general population

OBJECTIVE

A growing body of evidence has demonstrated the high prevalence and complexity of chronic physical multimorbidity defined as ≥2 chronic physical illness in people with psychiatric disorders. The present study aimed to assess differences in the prevalence and patterns of self-reported chronic physical illness and multimorbidity in the general and psychiatric populations.

METHODS

We performed a latent class analysis of 15 self-reported chronic physical illnesses on a sample of 1060 psychiatric patients and 837 participants from the general population.

RESULTS

Self-reported chronic physical illness and multimorbidity were significantly more prevalent in the population of psychiatric patients than in the general population (P < .001). Psychiatric patients had 27% (CI_95% 24% - 30%) higher age-standardized relative risk for chronic physical illness and a 31% (CI_95% 28% - 34%) higher for multimorbidity (P < .001). The number of chronic physical illnesses combinations was 52% higher in the psychiatric than in general population (255 vs 161 combinations respectively; P < .001). We identified four distinct latent classes: "Relatively healthy", "Musculoskeletal", "Hypertension and obesity", and "Complex multimorbidity" with no significant differences in the nature of multimorbidity latent classes patterns. The class "Relatively healthy" was significantly less (ARI = -25% (CI_95% -30% -21%), and the class "Hypertension and obesity" was significantly more prevalent in the population of psychiatric patients (ARI = 20% (CI_95% 17% - 23%).

CONCLUSIONS

These findings indicate that mental disorders are associated with an increased risk of a wide range of chronic physical illnesses and multimorbidity. There is an urgent need for the development of the guidelines regarding the physical healthcare of all individuals with mental disorders with multimorbidity in focus.

Predictors of falls and fractures leading to hospitalization in people with schizophrenia spectrum disorder: A large representative cohort study

AIM

To investigate predictors of falls/fractures leading to hospitalisation in people with schizophrenia-spectrum disorders.

METHODS

A historical cohort of people with schizophrenia-spectrum disorders (ICD F20-29) from 01/2006-12/2012 was assembled using data from the South London and Maudsley NHS Biomedical Research Centre Case Register. Falls/fractures were ascertained from a linkage to national hospitalisation data. Separate multivariate Cox regression analyses were employed to identify predictors of falls and fractures.

RESULTS

Of 11,567 people with schizophrenia-spectrum disorders (mean age 42.6 years, 43% female), 579 (incidence rate 12.79 per 1000 person-years) and 528 (11.65 per 1000 person-years) had at least one reported hospital admission due to a fall or fracture respectively and 822 patients had at least either a recorded fall or a fracture during this period (i.e. 7.1% of sample). Overall, 6.69 and 10.74 years of inpatient hospital stay per 1000-person years of follow-up occurred due to a fall and fracture respectively. 14(0.12%) and 28(0.24%) died due to a fall and fracture respectively. In Multivariable analysis, increasing age, white ethnicity, analgesics, cardiovascular disease, hypertension, diseases of the genitourinary system, visual disturbance and syncope were significant risk factor for both falls and fractures. A previous fracture (HR 2.05, 95% CI 1.53-2.73) and osteoporosis (HR 6.79, 95% CI 4.71-9.78) were strong risk factors for consequent fractures.

CONCLUSION

Comorbid physical health conditions and analgesic medication prescription were associated with higher risk of falls and fractures. Osteoporosis and previous fracture were strong predictors for subsequent fractures. Interventions targeting bone health and falls/fractures need to be developed and evaluated in these populations.

Physical activity pattern and cardiorespiratory fitness in individuals with schizophrenia compared with a population-based sample

OBJECTIVE

Thorough description of objectively assessed physical activity (PA) and sedentary time in people with schizophrenia is lacking, and previous studies comparing PA and cardiorespiratory fitness levels with healthy controls are limited by their small sample size and/or poor methodology.

METHOD

PA, sedentary behavior, and cardiorespiratory fitness level were assessed in 67 adults diagnosed with schizophrenia (EPHAPS study) and compared with a population-based sample of 2809 adults (NPASS study).

RESULTS

Fifty-five percent of the participants with schizophrenia had the unhealthy combination of not meeting the PA recommendations and sitting >7.5 h per day compared to 32% in the population-based sample. The PA level was especially low on weekday afternoons and evenings and throughout most of the day on weekends. The peak oxygen uptake for EPHAPS women was on average 23% lower than that for NPASS women, while EPHAPS men achieved on average 34% lower oxygen uptake on the exercise test compared with NPASS men.

CONCLUSION

People with schizophrenia are significantly less physically active, more sedentary, and have a poorer cardiorespiratory fitness level compared with the general population. Tailor-made PA interventions for people with schizophrenia should target their PA and sedentary behavior on afternoons and weekends especially.

[Somatic risks in elderly people with severe psychiatric illnesses]

BACKGROUND

Aged patients with severe mental illness (SMI) suffer from a high risk for functional impairment and a high load of somatic comorbidities. Until now, there has been a lack of systematic studies on this patient population in later life. This review summarizes the most significant somatic comorbidities and discusses the consequences for the medical care of this elderly group of patients.

METHODS

A selective narrative review based on PubMed research and observations in clinical practice.

RESULTS

Life expectancy is shortened by approximately 10 years in patients with SMI. The main reasons are somatic comorbidities, particularly lung and respiratory tract disorders, metabolic syndrome with its subsequent cardiovascular complications, in addition to osteoporosis and fractures with a complicated clinical course. Although life expectancy is shortened, the number of geriatric patients with SMI is increasing and requires special attention to be given to out-patient psychosocial care, self-management of somatic diseases, and to age-appropriate continuation of psychiatric treatment.

CONCLUSION

The life expectancy of patients with SMI is reduced because of their typically somatic comorbidity, but they are reaching increasingly advanced ages as a consequence of improved treatment possibilities. They often require special attention in their diagnostic work-up and support in the management of their treatment. Collaborative care linking medical geriatric and geronto-psychiatric treatment facilities is helpful in the the interdisciplinary therapy required.

[Psychiatric pharmacotherapy of older individuals with severe mental illness]

BACKGROUND

Chronic schizophrenia, depression, and bipolar disorders, among other chronic psychiatric disorders with onset at youth or early adulthood are often referred to as severe mental illness (SMI). Aging with SMI is associated with various psychosocial, physiological, and medical problems with potential impact on psychiatric pharmacotherapy.

OBJECTIVES

Determination and discussion of problems and special features of the psychopharmacological treatment of older persons with SMI and presentation of treatment recommendations for the distinct diagnoses.

MATERIALS AND METHODS

International literature and guidelines were searched. In addition, the basic literature and expert opinions are discussed.

RESULTS

General problems that influence the psychiatric pharmacotherapy of older persons with SMI include nonadherence, nonresponse, polypharmacy, and distinct pharmacokinetic changes with aging and somatic comorbidity. Psychotropic drugs may exhibit cardiovascular, metabolic, and neuropsychiatric risks, among others. The literature regarding effectiveness of psychotropic drugs, drug groups, or combination of drugs in older patients with SMI is scarce to nonexistent.

CONCLUSIONS

Drug treatment of older persons with SMI should be part of an overall treatment plan that also has to include social and psychotherapeutic components that address the specific problems of this population. Most importantly, psychiatric pharmacotherapy should consider these risks and the treatment should be tailored to a patient's individual risk profile. Due to a general lack of evidence in this special population, treatment strategies of standard guidelines should be adjusted with special consideration to physiological changes of age.

Can We Improve Physical Health Monitoring for Patients Taking Antipsychotics on a Mental Health Inpatient Unit?

BACKGROUND

Patients with severe mental illness are at risk of medical complications, including cardiovascular disease, metabolic syndrome, and diabetes. Given this vulnerability, combined with metabolic risks of antipsychotics, physical health monitoring is critical. Inpatient admission is an opportunity to screen for medical comorbidities. Our objective was to improve the rates of physical health monitoring on an inpatient psychiatry unit through implementation of an electronic standardized order set.

METHODS

Using a clinical audit tool, we completed a baseline retrospective audit (96 eligible charts) of patients aged 18 to 100 years, discharged between January and March 2012, prescribed an antipsychotic for 3 or more days. We then developed and implemented a standard electronic admission order set and provided training to inpatient clinical staff. We completed a second chart audit of patients discharged between January and March 2016 (190 eligible charts) to measure improvement in physical health monitoring and intervention rates for abnormal results.

RESULTS

In the 2012 audit, thyroid-stimulating hormone (TSH), blood pressure, blood glucose, fasting lipids, electrocardiogram (ECG), and height/weight were measured in 71%, 92%, 31%, 36%, 51%, and 75% of patients, respectively. In the 2016 audit, TSH, blood pressure, blood glucose, fasting lipids, ECG, and height/weight were measured in 86%, 96%, 96%, 64%, 87%, and 71% of patients, respectively. There were statistically significant improvements (P < 0.05) in monitoring rates for blood glucose, lipids, ECG, and TSH. Intervention rates for abnormal blood glucose and/or lipids (feedback to family doctor and/or patient, consultation to hospitalist, endocrinology, and/or dietician) did not change between 2012 and 2016.

CONCLUSIONS

Electronic standardized order set can be used as a tool to improve screening for physical health comorbidity in patients with severe mental illness receiving antipsychotic medications.