Metabolic syndrome in psychiatrically hospitalized patients treated with antipsychotics and other psychotropics

AMPlifying metabolic screening for inpatients on antipsychotic medications with a nurse-driven protocol

INTRODUCTION

Patients on antipsychotic medications are at higher risk of developing metabolic syndrome; nevertheless, metabolic screening for patients on antipsychotics is suboptimal.

METHODS

This project developed and implemented AMP (Antipsychotic Metabolic screening Protocol), a nurse-driven protocol on inpatient psychiatric units that allowed nursing staff to collect all components of a metabolic screening. Nurses working on units with AMP were surveyed pre- and post-implementation on perception of AMP and empowerment.

RESULTS

AMP significantly increased overall metabolic screening as well as the most frequently missing component (lipid panel). The screening rates pre-intervention were similar to those found in the literature (on average, only two-thirds of patients were screened). However, AMP improved the rate such that nine out of every ten patients on the units were screened. Nurses had a negative perception and no change in empowerment from AMP implementation.

CONCLUSIONS

AMP can be used to increase metabolic screening for patients on antipsychotics. Further research is needed to better understand adoptability of nurse-driven protocols in the psychiatric inpatient setting as well as other applications, such as smoking cessation or safety sitters.

Efficacy and Tolerability of Combination Treatments for Major Depression: Antidepressants plus Second-Generation Antipsychotics vs. Esketamine vs. Lithium

BACKGROUND

Successful treatment of major depressive disorder (MDD) can be challenging, and failures ("treatment-resistant depression" [TRD]) are frequent. Steps to address TRD include increasing antidepressant dose, combining antidepressants, adding adjunctive agents, or using nonpharmacological treatments. Their relative efficacy and tolerability remain inadequately tested. In particular, the value and safety of increasingly employed second-generation antipsychotics (SGAs) and new esketamine, compared to lithium as antidepressant adjuncts remain unclear.

METHODS

We reviewed randomized, placebo-controlled trials and used random-effects meta-analysis to compare odds ratio (OR) versus placebo, as well as numbers-needed-to-treat (NNT) and to-harm (NNH), for adding SGAs, esketamine, or lithium to antidepressants for major depressive episodes.

RESULTS

Analyses involved 49 drug-placebo pairs. By NNT, SGAs were more effective than placebo (NNT = 11 [CI: 9-15]); esketamine (7 [5-10]) and lithium (5 [4-10]) were even more effective. Individually, aripiprazole, olanzapine+fluoxetine, risperidone, and ziprasidone all were more effective (all NNT < 10) than quetiapine (NNT = 13), brexpiprazole (16), or cariprazine (16), with overlapping NNT CIs. Risk of adverse effects, as NNH for most-frequently reported effects, among SGAs versus placebo was 5 [4-6] overall, and highest with quetiapine (NNH = 3), lowest with brexpiprazole (19), 5 (4-6) for esketamine, and 9 (5-106) with lithium. The risk/benefit ratio (NNH/NNT) was 1.80 (1.25-10.60) for lithium and much less favorable for esketamine (0.71 [0.60-0.80]) or SGAs (0.45 [0.17-0.77]).

CONCLUSIONS

Several modern antipsychotics and esketamine appeared to be useful adjuncts to antidepressants for acute major depressive episodes, but lithium was somewhat more effective and better tolerated.

LIMITATIONS

Most trials of adding lithium involved older, mainly tricyclic, antidepressants, and the dosing of adjunctive treatments were not optimized.

Magnitude of metabolic syndrome and its predictors among patients on second-generation antipsychotic drugs at six psychiatry clinics and mental hospitals, in Addis Ababa, Ethiopia, 2019; Multicenter cross-sectional study

AIMS

Second-generation antipsychotics are an important component in the management of psychiatric conditions but their use can also lead to weight gain, diabetes, and dyslipidemia. Thus, this study aimed to assess the magnitude of metabolic syndrome and its predictors among patients who were on second-generation antipsychotic drugs at six psychiatry Hospitals, in Addis Ababa, Ethiopia, 2019.

METHOD

This study was conducted using a Multicenter cross-sectional study design. Medical charts of 510 patients on second-generation antipsychotic drugs who were selected by convenience sampling method and complete patients' charts were included in this study. Data was gathered using a checklist from patients' medical charts. To identify the determinants of metabolic syndrome, a logistic regression model was used.

RESULT

From a total of 510 patients' Medical charts on the second-generation antipsychotic drugs, 270 (52.9%) of them were females and 240 (47.1%) were males. The magnitude of metabolic syndrome among patients receiving second-generation antipsychotic drugs was found to be 88 (17.8%). Age, education, family history of cardiovascular disease, and type of second-generation antipsychotic drugs are found to be significantly associated factors with metabolic syndrome.

CONCLUSIONS

Considerable proportion of patients receiving second-generation antipsychotic medications have metabolic syndrome.

The efficacy and safety of sulforaphane as an adjuvant in the treatment of bipolar depressive disorder: Study protocol for a randomized, double-blinded, placebo-controlled, parallel-group clinical trial

BACKGROUND

Bipolar disorder (BD) is a chronic and disabling psychiatric disorder. The treatment of BD still remains a significant clinical challenge due to the complex nature of the disease. Nutraceutical therapy as adjunctive role is a promising therapy for BD. Sulforaphane (SFN), a broccoli extract, was reported to be effective for emotional problems and cognitive impairment. However, clinical research of SFN in the treatment of BD was rare. Therefore, this study is designed to evaluate the adjuvant role of SFN in the treatment of BD.

METHODS

This is a randomized, double-blinded, placebo-controlled, parallel-group clinical trial. A total of 100 patients who meet inclusion criteria will be assigned to receive quetiapine plus SFN or quetiapine plus placebo in a 1:1 ratio. The total duration of the study will be 12 weeks including 5 follow ups. The primary outcome is in the Montgomery-Asberg depression rating scale. The secondary outcomes are the quick inventory of depressive symptomatology-self report, Hamilton anxiety rating scale, young mania rating scale, cognitive function, inflammatory factors, and intestinal flora. Any adverse events will be recorded throughout the trial.

DISCUSSION

This trial will provide evidences to evaluate the efficacy and safety of SFN combined with quetiapine in the treatment of BD patients, as well as the adjuvant role of SFN in combination.

TRIAL REGISTRATION

This study protocol was registered at the Chinese clinical trial registry (ChiCTR2000028706).

Risk Factors of Metabolic Syndrome Among Patients Receiving Antipsychotics: A Retrospective Study

This study aimed to assess the differential effects of first-generation (FGA) and second-generation antipsychotics (SGA) on the prevalence of risk factors for metabolic syndrome among mentally ill patients in Qatar. We also wanted to check if there is proper adherence with the guidelines for prescribing antipsychotics and the monitoring of metabolic effects in this population. We collected the available retrospective data (socio-demographic, psychiatric, anthropometric, and metabolic measures) from the records of 439 patients maintained on antipsychotics. The majority were males, married, employed, having a psychotic disorder, and receiving SGA. Patients on SGA showed more obesity, higher BP, and more elevated triglycerides compared to those on FGA. The prevalence of the abnormal metabolic measures was high in this sample, but those on SGA showed a significantly higher prevalence of abnormal body mass index and BP. Obesity and hypertension were common in patients maintained on antipsychotics, especially those on SGA. Polypharmacy was common, and many metabolic measures were not monitored properly in those maintained on antipsychotics. More prospective studies with guided monitoring of the patients' clinical status and metabolic changes are needed to serve better this population of patients.

Bipolar depression: a major unsolved challenge

Depression in bipolar disorder (BD) patients presents major clinical challenges. As the predominant psychopathology even in treated BD, depression is associated not only with excess morbidity, but also mortality from co-occurring general-medical disorders and high suicide risk. In BD, risks for medical disorders including diabetes or metabolic syndrome, and cardiovascular disorders, and associated mortality rates are several-times above those for the general population or with other psychiatric disorders. The SMR for suicide with BD reaches 20-times above general-population rates, and exceeds rates with other major psychiatric disorders. In BD, suicide is strongly associated with mixed (agitated-dysphoric) and depressive phases, time depressed, and hospitalization. Lithium may reduce suicide risk in BD; clozapine and ketamine require further testing. Treatment of bipolar depression is far less well investigated than unipolar depression, particularly for long-term prophylaxis. Short-term efficacy of antidepressants for bipolar depression remains controversial and they risk clinical worsening, especially in mixed states and with rapid-cycling. Evidence of efficacy of lithium and anticonvulsants for bipolar depression is very limited; lamotrigine has long-term benefit, but valproate and carbamazepine are inadequately tested and carry high teratogenic risks. Evidence is emerging of short-term efficacy of several modern antipsychotics (including cariprazine, lurasidone, olanzapine-fluoxetine, and quetiapine) for bipolar depression, including with mixed features, though they risk adverse metabolic and neurological effects.

The role of weight gain in explaining the effects of antipsychotic drugs on positive and negative symptoms: An analysis of the CATIE schizophrenia trial

Second-generation antipsychotics are associated with moderate benefits in terms of improved schizophrenia symptoms, but also with higher rates of side-effects such as excessive weight gain (WG); a consensus on their efficacy has not been reached. To date, no study has evaluated the interplay of treatments and side-effects in a single framework, which is a critical step to clarify the role of side-effects in explaining the efficacy of these antipsychotics. We used recent methods for mediation and interaction to clarify the role of WG in explaining the effects of second-generation drugs on schizophrenia symptoms. We used data from 1460 participants in the CATIE trial, assigned to either perphenazine (first-generation comparison drug), olanzapine, quetiapine, risperidone, or ziprasidone. The primary outcome was an individual's score on the Positive and Negative Syndrome Scale (PANSS) for symptoms of schizophrenia after 9 months, separately evaluated as positive (PANSS+), negative (PANSS-), and total PANSS score. WG after 6 months was investigated as a potential mediator and effect modifier. Results showed that, by limiting WG, patients would benefit of a considerably better improvement in terms of PANSS symptoms. In the scenario of weight change being controlled between -2% and 1% for all participants, patients assigned to olanzapine would experience the highest significant improvements in both PANSS+ (-2.66 points; 95% CI: -4.98, -0.35), PANSS- (-1.59; 95% CI: -4.31, 1.14), and total PANSS (-6.11; 95% CI: -13.13, 0.92). In conclusion, occurrence of excessive WG hampers the potentially beneficial effects of second-generation antipsychotics, thus suggesting future directions for treatment and interventions.

Pharmacological treatment of adult bipolar disorder

We summarize evidence supporting contemporary pharmacological treatment of phases of BD, including: mania, depression, and long-term recurrences, emphasizing findings from randomized, controlled trials (RCTs). Effective treatment of acute or dysphoric mania is provided by modern antipsychotics, some anticonvulsants (divalproex and carbamazepine), and lithium salts. Treatment of BD-depression remains unsatisfactory but includes some modern antipsychotics (particularly lurasidone, olanzapine + fluoxetine, and quetiapine) and the anticonvulsant lamotrigine; value and safety of antidepressants remain controversial. Long-term prophylactic treatment relies on lithium, off-label use of valproate, and growing use of modern antipsychotics. Lithium has unique evidence of antisuicide effects. Methods of evaluating treatments for BD rely heavily on meta-analysis, which is convenient but with important limitations. Underdeveloped treatment for BD-depression may reflect an assumption that effects of antidepressants are similar in BD as in unipolar major depressive disorder. Effective prophylaxis of BD is limited by the efficacy of available treatments and incomplete adherence owing to adverse effects, costs, and lack of ongoing symptoms. Long-term treatment of BD also is limited by access to, and support of expert, comprehensive clinical programs. Pursuit of improved, rationally designed pharmacological treatments for BD, as for most psychiatric disorders, is fundamentally limited by lack of coherent pathophysiology or etiology.

Prevalence and determinants of physical activity in a mixed sample of psychiatric patients in Saudi Arabia

OBJECTIVES

To estimate prevalence of physical activity and its associations with various psychiatric disorders and the use of psychotropic medications.

METHODS

A cross-sectional observational study was carried out between July 2012 and June 2014. Patients were enrolled from a number of hospitals located in 5 regions of the Kingdom of Saudi Arabia.

RESULTS

A total of 1185 patients were included in current analysis: 796 were outpatients, and 389 were inpatients. Out of 1,185 patients, 153 (12.9%) were physically active. Much higher rates of physical activity were reported among males than females (15.9% versus 9.6%, p less than 0.001). According to the univariate analysis, higher rates of physical activity were positively correlated with primary bipolar disorders, the use of antianxiety medications and, to a lesser extent, use of antipsychotic medications, but they were negatively correlated with primary anxiety disorders, use of antidepressant medications, and use of multiple psychotropic medications. The associations between physical activity and primary bipolar disorders (odds ratio [OR]=2.47, p=0.002), use of antianxiety medications (OR=3.58, p=0.003), and use of multiple psychotropic medications (OR=0.33, p less than 0.001) remained significant after adjusting for demographic and clinical characteristics.

CONCLUSION

We report a variable but generally low prevalence of physical activity among a large, mixed sample of psychiatric patients in Saudi Arabia. These findings may highlight the importance of assessing physical activity status of psychiatric patients and the critical need for physical activity promotion programs among this group of disadvantaged patients.

High-density lipoprotein-cholesterol and antipsychotic medication in overweight inpatients with schizophrenia: post-hoc analysis of a Japanese nationwide survey

BACKGROUND

Patients with schizophrenia have an increased prevalence of metabolic disturbances compared with the general population. However, the mechanisms underlying the metabolic side effects of antipsychotics are unknown. The aim of the present study was to compare the levels of high-density lipoprotein (HDL)-cholesterol in Japanese schizophrenia patients medicated with olanzapine, risperidone, or aripiprazole monotherapy.

METHODS

This study was a post-hoc analysis of a nationwide survey, which included 433 Japanese outpatients with schizophrenia and 674 inpatients. A brief questionnaire was compiled that covered demographic data, systolic blood pressure, diastolic blood pressure, and HDL-cholesterol after reviewing the relevant literature and guidelines. To compare demographic and clinical characteristics, analysis of variance was performed for continuous variables and the chi-square test was performed for categorical variables. For comparisons of HDL-cholesterol levels among the three antipsychotic groups, analysis of covariance was carried out with age, diastolic blood pressure, chlorpromazine-equivalent dosage, and waist circumference as confounding variables after stratification by body mass index (BMI) for each outpatient group and inpatient group.

RESULTS

The mean age was 57.9 ± 14.0 years and the mean BMI was 23.4 ± 4.5 kg/m². HDL-cholesterol levels when stratified by BMI differed significantly (p = 0.019) between the three antipsychotic groups after age, diastolic blood pressure, chlorpromazine-equivalent dosage, and waist circumference in inpatients. A significant difference in HDL-cholesterol levels was only found in the overweight inpatient group, and no significant differences in HDL-cholesterol levels were found among the three antipsychotics for outpatients of all BMI stratifications or inpatients that were underweight or of normal weight. For post-hoc analysis of HDL-cholesterol levels in overweight inpatients, HDL-cholesterol was significantly lower in the olanzapine group than in the aripiprazole group (p = 0.023).

CONCLUSIONS

This study reveals a difference in HDL-cholesterol levels in overweight Japanese inpatients with schizophrenia resulting from the use of different antipsychotics. In the post-hoc analysis of HDL-cholesterol levels in overweight inpatients, HDL-cholesterol was significantly lower in the olanzapine group than in the aripiprazole group. Further studies incorporating more detailed evaluations, including diet and physical activity, are needed to clarify the differences in HDL-cholesterol according to antipsychotic use.

Complex Polypharmacy in Patients With Schizophrenia-Spectrum Disorders Before a Psychiatric Hospitalization: Prescribing Patterns and Associated Clinical Features

BACKGROUND

Current evidence-based guidelines provide unclear support for many common polypharmacy practices in schizophrenia. Excessive or complex polypharmacy (≥4 psychotropics) has been studied in patients with bipolar disorder, but not in schizophrenia to date.

METHODS

We conducted a digital medical record data extraction of 829 patients consecutively admitted to a psychiatric hospital and diagnosed as having schizophrenia-spectrum disorders.

RESULTS

In those prescribed psychiatric medication preadmission, 28.1% (n = 169) met the criteria for complex polypharmacy. Complex polypharmacy patients were older, female, white, and disabled, and had more comorbidities compared with those without complex polypharmacy. In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy patients.

CONCLUSIONS

Although there is little evidence to support complex polypharmacy in schizophrenia, rates were relatively high in patients requiring hospitalization, especially when they are also diagnosed as having comorbid psychiatric and medical conditions. Future research is needed to study the risk-benefit profile for these patients, especially considering their higher medical burden and related health risks.

Pharmacological treatment of bipolar depression

Bipolar depression remains a major challenge for psychiatric therapeutics. It is associated with disability and excess mortality, and accounts for three-quarters of the time spent in morbid states by treated patients with bipolar disorder. Major limitations of research on the treatment of depression in bipolar disorder include a paucity of short-term and lack of long-term trials, probably reflecting concern about inducing mania. In addition, polytherapy with multiple drugs appears to be widespread, but it is virtually untested for efficacy and safety. Here, we summarise the evidence concerning efficacy of treatment of bipolar depression with antidepressants, mood-stabilising anticonvulsants, lithium and second-generation antipsychotics.

LEARNING OBJECTIVES

•

Metabolic Syndrome in Psychotic Disorder Patients Treated With Oral and Long-Acting Injected Antipsychotics

Background: Severe mental illnesses are associated with increased risks for metabolic syndrome (MetS) and other medical disorders, often with unfavorable outcomes. MetS may be more likely with schizoaffective disorder (SzAff) than schizophrenia (Sz). MetS is associated with long-term antipsychotic drug treatment, but relative risk with orally administered vs. long-acting injected (LAI) antipsychotics is uncertain. Methods: Subjects (n = 151 with a DSM-IV-TR chronic psychotic disorder: 89 Sz, 62 SzAff), treated with oral or LAI antipsychotics were compared for risk of MetS, initially with bivariate comparisons and then by multivariate regression modeling. Results: Aside from measures on which diagnosis of MetS is based, factors preliminarily associated with MetS included antipsychotic drug dose, "high-risk" antipsychotics associated with weight-gain, older age and female sex. Defining factors associated with diagnosis of MetS ranked in multivariate regression as: higher fasting glucose, lower LDL cholesterol, higher diastolic blood pressure, and higher BMI. Risk of MetS with antipsychotics ranked: quetiapine ≥ clozapine ≥ paliperidone ≥ olanzapine ≥ risperidone ≥ haloperidol ≥ aripiprazole. Other associated risk factors in multivariate modeling ranked: higher antipsychotic dose, older age, and SzAff diagnosis, but not oral vs. LAI antipsychotics Conclusions: SzAff diagnosis and higher antipsychotic doses were associated with MetS, whereas orally vs. injected antipsychotics did not differ in risk of MetS.

Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and Psychological Empowerment

The prevalence of metabolic syndrome (MetS) in people with serious mental illness (SMI) has been well documented in the mental health literature. Despite the adoption of various guidelines for monitoring risk factors for diabetes and cardiovascular risk in this population, limited translation has occurred in actual practice (Hermes, Sernyak, & Rosenheck, 2013). The Institute of Medicine (IoM) (2009) has noted a lag time in the application of knowledge within clinical settings. Evidence-based practice was deemed as a means of improving healthcare outcomes through the use of science supported standards of care. Evidence-based practice (EBP) is a process to guide clinical decision making that involves the clinician's experience, well documented research findings, and the patient's values and choices (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). The IoM has established that by the year 2020, 90% of clinical decisions should be based upon current and scientifically based information (IoM, 2009). Psychiatric-mental health nurses are challenged to utilize EBP for clients with MetS in assessing their health status and discussing the findings, educating them about their current risk and life style modifications to mitigate risk, and finally, partnering with them to maximize health and quality of life.

The risk of new-onset diabetes in antidepressant users - A systematic review and meta-analysis

Background

Antidepressant Drugs (ADs) are among the most commonly prescribed medications in developed countries. The available epidemiological evidence suggests an association between AD use and higher risk of developing type 2 diabetes mellitus. However, some methodological issues make the interpretation of these results difficult. Moreover, very recent studies provided conflicting results. Given the high prevalence of both diabetes and AD use in many countries, clarifying whether this association is causal is of extreme relevance for the public health. The aim of the present study is to provide an up-to-date evaluation of the evidence in support of a causal role of ADs in inducing diabetes.

Methods and findings

A systematic literature search was conducted to identify relevant studies in MEDLINE (PubMed), PsycINFO, and International Pharmaceutical Abstracts (IPA) through 31^st December 2016. Only studies assessing the incidence of new-onset diabetes in subjects treated with ADs were included. Results were pooled using a random-effects meta-analysis. Moreover, we extensively reviewed the role of the different sources of bias that have been proposed to explain the association between AD and diabetes. Twenty studies met the inclusion criteria. In the meta-analysis, the association between AD use and diabetes was still evident after the inclusion of the recent negative studies [pooled relative risk = 1.27, 95% confidence interval (CI), 1.19–1.35; p<0.001]. None of the biases proposed by previous authors seemed able to fully explain the observed association.

Conclusions

This updated meta-analysis confirms the association between AD use and incident diabetes. It still remains a matter of debate whether single ADs exert a different effect on the risk of diabetes. Given the possible heterogeneity, we suggest that a classification of ADs according to their pharmacological profiles could be useful in better elucidating the nature of this association.

Attitudes toward antipsychotic treatment among patients with bipolar disorders and their clinicians: a systematic review

INTRODUCTION

Antipsychotics are recommended as first-line therapy for acute mania and maintenance treatment of bipolar disorder; however, published literature suggests their real-world use remains limited. Understanding attitudes toward these medications may help identify barriers and inform personalized therapy. This literature review evaluated patient and clinician attitudes toward the use of antipsychotics for treating bipolar disorder.

MATERIALS AND METHODS

A systematic search of the Cochrane Library, Ovid MEDLINE, Embase, and BIOSIS Previews identified English language articles published between January 1, 2000, and June 15, 2016, that reported attitudinal data from patients, health care professionals, or caregivers; treatment decision-making; or patient characteristics that predicted antipsychotic use for bipolar disorder. Results were analyzed descriptively.

RESULTS

Of the 209 references identified, 11 met the inclusion criteria and were evaluated. These articles provided attitudinal information from 1,418 patients with bipolar disorder and 1,282 treating clinicians. Patients' attitudes toward antipsychotics were generally positive. Longer duration of clinical stability was associated with positive attitudes. Implementation of psychoeducational and adherence enhancement strategies could improve patient attitudes. Limited data suggest clinicians' perceptions of antipsychotic efficacy and tolerability may have the greatest impact on their prescribing patterns. Because the current real-world evidence base is inadequate, clinician attitudes may reflect a relative lack of experience using antipsychotics in patients with bipolar disorder.

CONCLUSION

Although data are very limited, perceived tolerability and efficacy concerns shape both patient and clinician attitudes toward use of antipsychotic drugs in bipolar disorder. Additional studies are warranted.

Development of a Web-Based Clinical Decision Support System for Drug Prescription: Non-Interventional Naturalistic Description of the Antipsychotic Prescription Patterns in 4345 Outpatients and Future Applications

PURPOSE

The emergence of electronic prescribing devices with clinical decision support systems (CDSS) is able to significantly improve management pharmacological treatments. We developed a web application available on smartphones in order to help clinicians monitor prescription and further propose CDSS.

METHOD

A web application (www.MEmind.net) was developed to assess patients and collect data regarding gender, age, diagnosis and treatment. We analyzed antipsychotic prescriptions in 4345 patients attended in five Psychiatric Community Mental Health Centers from June 2014 to October 2014. The web-application reported average daily dose prescribed for antipsychotics, prescribed daily dose (PDD), and the PDD to defined daily dose (DDD) ratio.

RESULTS

The MEmind web-application reported that antipsychotics were used in 1116 patients out of the total sample, mostly in 486 (44%) patients with schizophrenia related disorders but also in other diagnoses. Second generation antipsychotics (quetiapine, aripiprazole and long-acting paliperidone) were preferably employed. Low doses were more frequently used than high doses. Long acting paliperidone and ziprasidone however, were the only two antipsychotics used at excessive dosing. Antipsychotic polypharmacy was used in 287 (26%) patients with classic depot drugs, clotiapine, amisulpride and clozapine.

CONCLUSIONS

In this study we describe the first step of the development of a web application that is able to make polypharmacy, high dose usage and off label usage of antipsychotics visible to clinicians. Current development of the MEmind web application may help to improve prescription security via momentary feedback of prescription and clinical decision support system.

Factors associated with overweight and obesity in schizophrenia, schizoaffective and bipolar disorders

Evidence suggests abnormal bioenergetic status throughout the body in psychotic disorders. The present study examined predictors of elevated body mass index (BMI) across diagnostic categories of schizophrenia, schizoaffective and bipolar disorders. In a cross-sectional study, we studied demographic and clinical risk factors for overweight and obesity in a well-characterized sample of 262 inpatients and outpatients with schizophrenia (n=59), schizoaffective disorder (n=81) and bipolar I disorder (n=122). Across the three diagnostic categories, the prevalence of overweight (29.4%) and obesity (33.2%) combined was 62.6% (164/262). Logistic regression analyses, adjusted for age, sex and ethnicity, showed that schizoaffective disorder, lifetime major depressive episode, presence of prior suicide attempt, and more than 5 lifetime hospitalizations were significantly associated with BMI≥25. Patients with schizophrenia had significantly lower risk for overweight and obesity. Overall, we found that affective components of illness were associated with elevated BMI in our cross-diagnostic sample. Our results show that patients with schizoaffective disorder have a greater risk for obesity. Identifying predictors of elevated BMI in patients with psychotic and mood disorders will help prevent obesity and related cardiovascular and cerebral complications. Future studies are needed to elucidate the mechanistic nature of the relationship between obesity and psychiatric illness.

High H1-affinity antidepressants and risk of metabolic syndrome in bipolar disorder

RATIONALE

Metabolic syndrome (MetS) is common in patients with bipolar disorder, with a relative risk of 1.6-2 compared to the general population. The increased risk is believed to be due to unhealthy lifestyles and use of medications. Although antipsychotics and mood stabilizers have been associated with weight gain and MetS, the impact of antidepressants has not been comprehensively evaluated.

OBJECTIVE

The objective of the study is to assess the risk of MetS in patients exposed to different types of antidepressants.

METHODS

In this cross-sectional study, 294 patients with bipolar disorder were consecutively recruited. MetS was diagnosed according to NCEP ATP-III modified criteria. Antidepressants used by the patients were classified according to the usual nomenclature (SSRI, TCA, SNRI, and other antidepressants) and a pharmacodynamic classification taking into account histamine 1-receptor (H1-R) affinity.

RESULTS

Use of antidepressants in general was not associated with MetS (prevalence ratio [PR], 1.08; 95% confidence interval, 0.73 to 1.62; p = 0.70). However, subjects using H1-R high-affinity antidepressants (N = 15) showed a substantial increase in the prevalence of MetS (PR, 2.17; 95 % confidence interval, 1.24 to 3.80; p = 0.007). When we included the inhibition constant (Ki) as a continuous covariate in the models, we found an inverse association between Ki and prevalence of MetS (p = 0.004).

CONCLUSION

We observed for the first time in a clinical setting that a pharmacodynamic-based classification of antidepressants could be more useful than the traditional one to predict the risk of MetS in patients with bipolar disorder. Clinical consequences may be relevant. However larger studies are warranted to generalize these results.

Metabolic issues in patients affected by schizophrenia: clinical characteristics and medical management

Patients affected by psychotic disorders are more likely to develop high rates of co-morbidities, such as obesity, type 2 diabetes, dyslipidemias, hypertension, metabolic syndrome, myocardial infarction, stroke etc., in the long-term. These morbidities have a significant impact on the life-expectancy of these patients. Patients with chronic psychoses show a 2–3-fold increased risk of death mostly from cardiovascular and metabolic diseases. Although there may be an independent link, between schizophrenia and metabolic conditions the cardio-metabolic risk is mostly related to an unhealthy lifestyle and the usage of antipsychotic agents (especially Second Generation Antipsychotics or atypical) even when these remain effective treatments in the management of major psychoses. Recently, many international organizations have developed screening and monitoring guidelines for the control of modifiable risk factors in order to reduce the rate of co-morbidity and mortality among patients affected by schizophrenia. This paper is a review of current knowledge about the metabolic issues of patients affected by schizophrenia and describes clinical characteristics and medical management strategies for such conditions.

Impairment of left ventricular function early in treatment with clozapine: a preliminary study

This preliminary prospective study evaluated cardiac status in 15 treatment-resistant schizophrenia patients (aged 18-55 years) without evidence of cardiovascular disease. Patients underwent clinical assessment, blood tests, ECG, and echocardiography before and during clozapine treatment for 4 weeks as doses increased from 25 to 100 mg/day. Serum concentrations of high-sensitivity C-reactive protein, troponin-I, brain natriuretic peptide, and clozapine+norclozapine were assayed at week 3; ECG and echocardiography were repeated at week 4. At moderate serum drug concentrations (124 ng/ml), the heart rate increased by 10% and high-sensitivity C-reactive protein levels were slightly elevated, but troponin-I and brain natriuretic peptide levels were not elevated. Echocardiographic indices indicated declining left ventricular (LV) diastolic and systolic function in 60-80% of participants, with an increase in systolic pulmonary artery pressure, A-wave velocity, and LV myocardial performance index by 16-24% in 60-80% of participants and a decrease in the E/A ratio by 29% in 73% of participants - all uncorrelated with drug concentrations. Early treatment with moderate doses of clozapine was associated with subclinical but substantial decreases in LV functioning in surprisingly high proportions of participants. Studies with more participants, higher drug doses, and long-term follow-up are needed to confirm and determine the course of the observed abnormalities and to evaluate their relationship with rare clinical cardiotoxicity associated with clozapine.

Schizoaffective disorder and metabolic syndrome: A meta-analytic comparison with schizophrenia and other non-affective psychoses

People with psychotic disorders, including schizophrenia (SCZ), schizoaffective disorder (SD), or other non-affective psychoses (ONAP), have a higher risk of metabolic syndrome (MetS) than general population. However, previous meta-analyses failed to explore if people with SD are more likely to suffer from MetS than SCZ and ONAP. We carried out a systematic review and meta-analysis comparing rates of MetS in SD with those in SCZ or ONAP. We searched main electronic databases for relevant articles published up to January 2015, and for unpublished data, contacting corresponding authors, to minimize selective reporting bias. Odds ratios (ORs) based on random effects models, with 95% confidence intervals (CIs), and heterogeneity (I(2)), were estimated. We performed leave-one-out, quality-based, and subgroups analyses to check findings validity. Testing for publication bias, Egger's test estimates were reported. We included 7616 individuals (1632 with SD and 5984 with SCZ/ONAP) from 30 independent samples. SD, as compared with SCZ/ONAP, had a random-effect pooled OR (95%CI) for MetS of 1.41 (1.23-1.61; p < 0.001; I(2) = 5%). No risk of publication bias was found (p = 0.85). Leave-one-out, sensitivity, and subgroups analyses confirmed the association. To our knowledge, this is the first meta-analysis comparing MetS comorbidity between individuals with SD and those with SCZ or ONAP. SD subjects are more likely to suffer from MetS, with consistent findings across the studies included. However, the role of explanatory factors of this association, and the relative contribution of MetS subcomponents, deserve further research.

Nursing Care for Lifestyle Behavioral Change

The purpose of this pilot study was to determine if metabolic risk factors can be stabilized or improved with weekly motivational interviewing/coaching and medical follow-up care focused on lifestyle behavioral change in individuals with serious mental illness. Individuals were followed for 18 weeks following discharge from an inpatient psychiatric service. All individuals were prescribed an antipsychotic medication and had at least two risk factors for metabolic syndrome. Weight, waist circumference, blood pressure, LDLs, triglycerides, and blood glucose levels were evaluated during the study period. In addition, each individual selected a lifestyle behavior to improve over the 18-week period. Weekly motivational interviewing, and staggered health promotion appointments were designed to keep individuals focused on health and behavior change. While some individuals showed improvement, others showed deterioration in the physiological markers for metabolic syndrome. Only a small number completed the 18-week study. The nature of current psychiatric care is focused on rapid stabilization and discharge; individuals with serious mental illness may have difficulty focusing on lifestyle behavioral change while transitioning to independent living following an acute exacerbation of mental illness.

A network meta-analysis on comparative efficacy and all-cause discontinuation of antimanic treatments in acute bipolar mania

BACKGROUND

Evidence synthesis methods enabling direct and indirect comparisons over the entire set of relevant clinical data produce quantitative point estimates for the treatments contrasts between competing interventions, and provide a hierarchical rank ordering between them. We aimed to provide evidence-based guidance on the efficacy and all-cause discontinuation of antimanic treatments.

METHOD

We conducted a network meta-analysis within a Bayesian framework. We searched all standard literature databases without language restrictions up to 15 January 2014 to identify reports of short-term, randomized, blinded trials of putative antimanic drugs as monotherapy for adults with bipolar-I mania.

RESULTS

Altogether, 14256 manic patients randomized to one of 18 active treatments or placebo provided 95 direct comparisons on 128 data points. For the primary outcome, standardized mean difference as Hedges' g (standardized mean difference; SMD), the hierarchies indicated by surface under the cumulative ranking (SUCRA) probabilities were in agreement with the point estimates for all antimanic drugs identified as effective. For the 12 effective antimanic drugs on clinical use, SMDs against placebo ranged from 0.32 to 0.66 without superiority of one over another, except for risperidone v. aripiprazole and valproate. Aripiprazole, olanzapine, quetiapine, risperidone, and valproate had less all-cause discontinuation rates than placebo. Sensitivity analysis by drug class indicated similar efficacy profiles for haloperidol, second-generation antipsychotics, and mood stabilizers.

CONCLUSIONS

Hierarchical rank ordering by comparative efficacy and risk of all-cause discontinuations should help to guide antimanic treatment choices by clinicians, healthcare policy makers, and guideline developers.

Educational intervention to increase detection of metabolic syndrome in patients at community mental health centers

The prevalence of metabolic syndrome and associated illness is approximately double in individuals with mental illness compared with the general public. An educational intervention on metabolic syndrome was provided to mental health counselors, who performed intake assessments of patients newly admitted to two outpatient mental health facilities. Researchers of the current study first measured mastery of metabolic syndrome content following the educational intervention; they then conducted a chart audit on new admissions to measure changes in clinician behavior. Prior to the intervention, neither facility screened for metabolic syndrome at intake or referred patients with a body mass index (BMI) >25 for medical evaluation. A paired t test showed no significant difference in the educational pre-posttest scores; however, following the intervention, 53 of 132 patients had a documented BMI >25, and 47 of 53 patients were referred to a primary care provider for evaluation. The current study's findings suggest that mental health counselors who screen for metabolic syndrome and associated illnesses will increase the rate of detection of these chronic conditions.

Factors associated with length of psychiatric hospitalization

OBJECTIVE

Criteria for psychiatric hospitalization have undergone marked changes. Efforts to limit length-of-hospitalization risk greater morbidity at discharge and increased needs for appropriate aftercare. Accordingly, we evaluated factors associated with length of psychiatric hospitalization and aftercare-types.

METHODS

We reviewed medical records of 589 patients with major psychiatric disorders hospitalized in a university-affiliated, not-for-profit psychiatric hospital to identify characteristics associated with length of hospitalization, types of aftercare and insurance coverage, using standard bivariate and multivariate analytical methods.

RESULTS

Notable factors associated with longer hospitalization included: more highly supervised aftercare, diagnosis of schizophrenia or schizoaffective>affective disorders, longer illnesses, higher antipsychotic doses and more complex drug-treatments at discharge, lower GAF functional status, unemployment, being unmarried, as well as public vs. private insurance. Multivariate modeling sustained association of longer hospitalization with higher antipsychotic doses, more structured aftercare, public insurance, lower GAF scores, and diagnoses of chronic psychotic disorders. Structured aftercare was associated with younger age, fewer years ill, and private insurance, but varied little by diagnosis and was unrelated to ethnicity. Public insurance was associated notably with being unemployed, unmarried, less functional, having a chronic psychotic disorder for more years, and lack of structured aftercare.

CONCLUSIONS

Illness severity and functional impairment may modulate efforts to limit psychiatric hospitalization. Higher-level aftercare was associated with illness and disability factors as well as with private insurance; public insurance was associated with dysfunction, unemployment and chronic illness, as well as longer hospitalization.

Validation of a claims-based antipsychotic polypharmacy measure

Purpose Given the metabolic and neurologic side effects of antipsychotics and concerns about the increased risks associated with concomitant use, antipsychotic polypharmacy is a quality concern. This study assessed the operating characteristics of a Medicaid claims-based measure of antipsychotic polypharmacy. Methods A random sample from 10 public mental health clinics and 312 patients met criteria for this study. Medical record extractors were blind to measure status. We examined the prevalence, sensitivity, specificity, and positive predictive value (PPV) in Medicaid claims, testing nine different definitions of antipsychotic polypharmacy, including >14, >60, or >90 days concurrent use of ≥2 antipsychotic agents, each with allowable gaps of up to 0, 14, or 32 days in days' supply of antipsychotic medications. Results All Medicaid claims measure definitions tested had excellent specificity and PPV (>91%). Good to excellent sensitivity was dependent upon use of a 32-day gap allowance, particularly as duration of concurrent antipsychotic use increased. The proposed claims-based measure (90-day concurrent use of ≥2 or more antipsychotics, allowing for a 32-day gap) had excellent specificity (99.1%, 95%CI: 98.2-99.6) and PPV (90.9%, 95%CI: 83.1-95.7) with good sensitivity (79.4%, 95%CI: 70.4-86.6). The overall level of concordance between claims and medical record-based categorization of antipsychotic polypharmacy was high (96.4%, n = 301/312 clients, Cohen's K = 84.7, 95%CI: 75.9-93.5). Discrepant cases were reviewed, and implications are discussed. Conclusions Administrative claims data can be used to construct valid measures of antipsychotic polypharmacy.

Improvements in metabolic abnormalities among overweight schizophrenia and bipolar disorder patients

PURPOSE

As weight-gain and metabolic abnormalities during treatment with psychotropic drugs are of great concern, we evaluated effects of psycho-education and medical monitoring on metabolic changes among severely mentally ill patients.

MATERIALS AND METHODS

During repeated, systematic psycho-education about general health among 66 consecutive patients diagnosed with DSM-IV-TR schizophrenia (n=33) or type-I bipolar disorder (n=33), we evaluated (at intake 1, 2, 3, and 6 months) clinical psychiatric status, treatments and doses, recorded physiological parameters, and assessed attitudes about medication.

RESULTS

At intake, patients with schizophrenia vs bipolar disorder were receiving 3-7 times more psychotropic medication, with 14% higher initial body-mass index (BMI: 29.1 vs 25.6 kg/m²), 12 times more obesity, and significantly higher serum lipid concentrations. During 6-months follow-up, among bipolar disorder patients, polytherapy and serum lipid concentrations declined more than among schizophrenia patients (e.g., total cholesterol+triglycerides, by 3.21 vs 1.75%/month). BMI remained stable. Declining lipid levels were associated with older age, bipolar disorder, being unemployed, higher antipsychotic doses, and lower initial BPRS scores (all P ≤ 0.001).

CONCLUSIONS

Psychotropic treatments were more complex, and metabolic measures more abnormal among bipolar disorder than schizophrenia patients. Intensive psycho-education, clinical monitoring, and encouragement of weight-control for six months were associated with improvements in metabolic measures (but not to BMI), and more realistic attitudes about medication.

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

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

Overview of antidepressant treatment of bipolar depression

Bipolar depression remains a major unresolved challenge for psychiatric therapeutics. It is associated with significant disability and mortality and represents the major proportion of the approximately half of follow-up time spent in morbid states despite use of available treatments. Evidence regarding effectiveness of standard treatments, particularly with antidepressants, remains limited and inconsistent. We reviewed available clinical and research literature concerning treatment with antidepressants in bipolar depression and its comparison with unipolar depression. Research evidence concerning efficacy and safety of commonly used antidepressant treatments for acute bipolar depression is very limited. Nevertheless, an updated meta-analysis indicated that overall efficacy was significantly greater with antidepressants than with placebo-treatment and not less than was found in trials for unipolar major depression. Moreover, risks of non-spontaneous mood-switching specifically associated with antidepressant treatment are less than appears to be widely believed. The findings encourage additional efforts to test antidepressants adequately in bipolar depression, and to consider options for depression in types I vs. II bipolar disorder, depression with subsyndromal hypomania and optimal treatment of mixed agitated-dysphoric states--both short- and long-term. Many therapeutic trials considered were small, varied in design, often involved co-treatments, or lacked adequate controls.

Negative Affective Features in 516 Cases of First Psychotic Disorder Episodes: Relationship to Suicidal Risk

OBJECTIVES

Plausible candidates of psychopathological phenomena that may associate with or anticipate suicidal risk, include negative affects, including admixtures of dysphoria, depression and anxiety described mainly in nonpsychotic disorders. We ascertained the distribution of such affective features in various first-episode psychotic disorders and correlated these and other clinical and antecedent features with intake suicidal status.

METHODS

We evaluated 516 adult subjects in first-lifetime episodes of various DSM-IV-TR psychotic disorders. Blinded, protocol-guided, assessments of clinical features ascertained in SCID examinations, self- and family reports and clinical records supported analyses of associations of suicide attempts at first-psychotic episodes with antecedent and intake clinical characteristics, including negative affects and diagnoses, using standard bivariate and multivariate methods.

RESULTS

Negative affective features in various combinations were prevalent (90%) and at >75% in both affective and nonaffective psychotic disorders; anxious depression was most common (22%). We identified antecedent and intake clinical factors preliminarily associated with suicide attempts. Factors remaining independently associated in multivariate logistic modelling (ranked by OR) were: (a) prior suicide attempt, (b) prior aggressive assault, (c) bipolar-mixed state or psychotic major depression diagnosis, (d) prior dysphoria, (e) intake dysphoric-anxiousdepression, (f) prior impulsivity, (g) previous affective instability, (h) previous nonpsychotic depression, (i) previous decline in vital drive, and (j) prior sleep disturbances.

CONCLUSIONS

Various types and combinations of negative affective features (especially anxious depression with and without dysphoria) were prevalent across nonaffective as well as affective first psychotic episodes and strongly associated with suicide attempts. These findings extend previous observations in nonpsychotic disorders.