Long-term health considerations in schizophrenia: metabolic effects and the role of abdominal adiposity

Biomarkers as proxies for cognitive reserve: The role of high density lipoprotein cholesterol in first episode of psychosis

INTRODUCTION

The proxies used to compose cognitive reserve (CR) for patients of a first episode of psychosis (FEP) have varied in the literature. The development of FEP is linked to peripheral pathways of the central nervous system, yet despite this knowledge, no research has considered the introduction of biomarkers as proxies for CR. Meanwhile, schizophrenia has been linked to the metabolic system, indicating that alterations in the levels of biological parameters, in particular high-density lipoproteins (HDL), cause worse global functioning and cognitive impairment. For these reasons, the present study aimed to create a quantifiable and objective CR index that adjusts for the multifactorial nature of FEP.

MATERIALS AND METHODS

We included 668 FEP patients and 217 healthy controls. Participants were assessed for sociodemographic information, years of education, employment status, premorbid IQ and biological parameters: waist circumference, hypertension, and levels of HDL, triglycerides, and glucose.

RESULTS

The findings suggest that the years of education proxy showed correlational and higher relationship with HDL levels for both FEP patients (r=0.23, b=0.185) and controls (r=0.31, b=0.342). We found that the CR index composed of years of education and HDL levels showed a higher explanatory power for the phenomenon than the classical CR index composed of years of education, employment status and premorbid IQ.

CONCLUSIONS

This article proposes an objective and quantifiable method to measure CR that is more the multifactorial nature of FEP.

Cardiometabolic health risks, lifestyle behaviours and quality of life in people diagnosed with early psychosis - A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with schizophrenia have poor cardiometabolic health, with elevated 10-year cardiovascular disease risk (CVD-R) scores and low quality of life (QOL). There is a lack of understanding about CVD-R scores in people diagnosed with early psychosis and no studies have quantified CVD-R using the QRISK^® 3 calculator in this client group. Establishing potential relationships between modifiable lifestyle behaviours/treatment characteristics with CVD-R or QOL may identify targets for early intervention. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to quantify the individual 10-year CVD-R of people diagnosed with early psychosis utilising the QRISK^® 3 calculator. This is also the first study to investigate relationships between QOL and CVD-R and lifestyle factors in a cohort of Thai people diagnosed with early psychosis. We observed low levels of physical health-related QOL and high levels of CVR-R despite participants reporting relatively positive lifestyle behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The cardiometabolic health state of this client group warrants as much attention as for those with an enduring severe mental illness; early preventative interventions are warranted. It may be useful to routinely quantify the CVD-R of people diagnosed with early psychosis using the QRISK^® 3 calculator, even in the absence of immediate concerns about lifestyle behaviours. Mental health nurses should utilise evidence-based approaches such as increasing activity levels, dietary counselling and behaviour change interventions to mitigate poor physical health in this client group. ABSTRACT: Introduction People diagnosed with schizophrenia have poor cardiometabolic health, with elevated 10-year cardiovascular disease risk (CVD-R) scores and poor quality of life (QOL). There is lack of understanding of these issues in early psychosis. Aims To quantify CVD-R in people diagnosed with early psychosis and profile their obesity prevalence, lifestyle behaviours and QOL. Secondary aim was to explore associations between lifestyle behaviours/treatment characteristics and CVD-R/QOL. Method Baseline data from 81 RCT participants were used to profile cardiometabolic health risks (QRISK^® 3, BMI and waist circumference). Participants self-reported lifestyle behaviours and QOL. Relationships between modifiable treatment/lifestyle factors and QOL/CVD-R were explored. Results Participants' relative risk for CVD over 10 years was 1.93 times higher than healthy counterparts; 39% also had an obese BMI and physical QOL was poor. No significant associations were observed between CVD-R or QOL with treatment characteristics and lifestyle factors. Discussion Despite positive lifestyle behaviours, participants had elevated CVD-R scores and poor physical health-related QOL. Quantifying CVD-R with QRISK^® 3 may highlight the need for health promotion interventions. Implications for practice Mental health professionals should be aware that elevated CVD-R exists in the context of relatively healthy lifestyle behaviours and utilise evidence-based interventions to address these issues.

Metabolic screening in primary care for patients with schizophrenia or schizoaffective disorder and taking antipsychotic medication

INTRODUCTION Life expectancy in patients with schizophrenia is 15-20 years less than the general population. A dominant cause of morbidity and mortality in these patients is cardiovascular disease. Adverse consequences of modifiable cardiovascular risk factors can be reduced by regular monitoring of metabolic outcomes and intervention if required. AIM To evaluate the metabolic screening in primary care for patients with schizoaffective disorders managed in primary care. To show the usefulness of combining simple practice audits in evaluating such areas of clinical practice. METHODS An audit was undertaken in eight general practices in the Waikato and Bay of Plenty regions of New Zealand. Specifically, the monitoring of patients with schizophrenia or schizoaffective disorder whose antipsychotic medication was prescribed by primary care doctors was audited. Patient monitoring was compared to the guideline recommendation of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Best Practice Advisory Centre (BPAC). RESULTS In total, 117 patients were included in the audit and none were fully monitored, as recommended by the RANZCP guidelines. Although two-thirds of patients had been evaluated for glycosylated haemoglobin (HbA1c), lipids, blood pressure, complete blood count and weight, <10% of patients had had prolactin, waist circumference or electrocardiogram measurements recorded. The proportion of patients having a HbA1c measured was also significantly higher in younger patients and patients who were non-Māori or enrolled with an urban practice (all P<0.05). When using the simplified BPAC guidelines, half of all patients were correctly monitored. DISCUSSION These findings show there is room for improvement in the monitoring of patients receiving antipsychotic medication in primary care. This may indicate the need for clear guidance and general practitioner education around the monitoring requirements of these patients. Alternatively, a more simplified monitoring protocol may need to be developed. This audit has also shown that there is value in several practices completing the same audit and providing a larger cohort of patients for pooled data analysis.

A Focused Review of the Metabolic Side-Effects of Clozapine

The second generation antipsychotic drug clozapine represents the most effective pharmacotherapy for treatment-resistant psychosis. It is also associated with low rates of extrapyramidal symptoms and hyperprolactinemia compared to other antipsychotic drugs. However, clozapine tends to be underutilized in clinical practice due to a number of disabling and serious side-effects. These are characterized by a constellation of metabolic side-effects which include dysregulation of glucose, insulin, plasma lipids and body fat. Many patients treated with clozapine go on to develop metabolic syndrome at a higher rate than the general population, which predisposes them for Type 2 diabetes mellitus and cardiovascular disease. Treatments for the metabolic side-effects of clozapine vary in their efficacy. There is also a lack of knowledge about the underlying physiology of how clozapine exerts its metabolic effects in humans. In the current review, we focus on key studies which describe how clozapine affects each of the main symptoms of the metabolic syndrome, and cover some of the treatment options. The clinical data are then discussed in the context of preclinical studies that have been conducted to identify the key biological substrates involved, in order to provide a better integrated overview. Suggestions are provided about key areas for future research to better understand how clozapine causes metabolic dysregulation.

Atypical antipsychotics-induced metabolic syndrome and nonalcoholic fatty liver disease: a critical review

The atypical antipsychotics (AAPs) have been used as first-line drugs in psychiatric practice for a wide range of psychotic disorders, including schizophrenia and bipolar mania. While effectively exerting therapeutic effects on positive and negative symptoms, as well as cognitive impairments in schizophrenia patients, these drugs are less likely to induce extrapyramidal symptoms compared to typical antipsychotics. However, the increasing application of them has raised questions on their tolerability and adverse effects over the endocrine, metabolic, and cardiovascular axes. Specifically, AAPs are associated to different extents, with weight gain, metabolic syndrome (MetS), and nonalcoholic fatty liver disease (NAFLD). This article summarized clinical evidence showing the metabolic side effects of AAPs in patients with schizophrenia, and experimental evidence of AAPs-induced metabolic side effects observed in animals and cell culture studies. In addition, it discussed potential mechanisms involved in the APPs-induced MetS and NAFLD.

Establishing post mortem criteria for the metabolic syndrome: an autopsy based cross-sectional study

BACKGROUND

Individuals who suffer from mental illness are more prone to obesity and related co-morbidities, including the metabolic syndrome. Autopsies provide an outstanding platform for the macroscopic, microscopic and molecular-biological investigation of diseases. Autopsy-based findings may assist in the investigation of the metabolic syndrome. To utilise the vast information that an autopsy encompasses to elucidate the pathophysiology behind the syndrome further, we aimed to both develop and evaluate a method for the post mortem definition of the metabolic syndrome.

METHODS

Based on the nationwide Danish SURVIVE study of deceased mentally ill, we established a set of post mortem criteria for each of the harmonized criteria of the metabolic syndrome. We based the post mortem (PM) evaluation on information from the police reports and the data collected at autopsy, such as anthropometric measurements and biochemical and toxicological analyses (PM information). We compared our PM evaluation with the data from the Danish health registries [ante mortem (AM) information, considered the gold standard] from each individual.

RESULTS

The study included 443 deceased individuals (272 male and 171 female) with a mean age of 50.4 (± 15.5) years and a median (interquartile range) post mortem interval of 114 (84-156) hours. We found no significant difference when defining the metabolic syndrome from the PM information in comparison to the AM information (P = 0.175). The PM evaluation yielded a high specificity (0.93) and a moderate sensitivity (0.63) with a moderate level of agreement compared to the AM evaluation (Cohen's κ = 0.51). Neither age nor post mortem interval affected the final results.

CONCLUSIONS

Our model of a PM definition of the metabolic syndrome proved reliable when compared to the AM information. We believe that an appropriate estimate of the prevalence of the metabolic syndrome can be established post mortem. However, while neither the PM nor the AM information is exhaustive in terms of defining an individual's health status, a superlative estimate may be obtained by combining the PM and the AM information. With this model, we open up the possibility of utilising autopsy data for future studies of the metabolic syndrome.

Weight changes before and after lurasidone treatment: a real-world analysis using electronic health records

BACKGROUND

Severe and persistent mental illnesses, such as schizophrenia and bipolar disorder, are associated with increased risk of obesity compared to the general population. While the association of lurasidone and lower risk of weight gain has been established in short and longer-term clinical trial settings, information about lurasidone's association with weight gain in usual clinical care is limited. This analysis of usual clinical care evaluated weight changes associated with lurasidone treatment in patients with schizophrenia or bipolar disorder.

METHODS

A retrospective, longitudinal analysis was conducted using de-identified electronic health records from the Humedica database for patients who initiated lurasidone monotherapy between February 2011 and November 2013. Weight data were analyzed using longitudinal mixed-effects models to estimate the impact of lurasidone on patient weight trajectories over time. Patients' weight data (kg) were tracked for 12-months prior to and up to 12-months following lurasidone initiation. Stratified analyses were conducted based on prior use of second-generation antipsychotics with medium/high risk (clozapine, olanzapine, quetiapine, or risperidone) versus low risk (aripiprazole, ziprasidone, first-generation antipsychotics, or no prior antipsychotics) for weight gain.

RESULTS

Among the 439 included patients, the mean age was 42.2 years, and 69.7% were female. The average duration of lurasidone treatment across all patients was 55.2 days and follow-up duration after the index date was 225.1 days. The estimated impact of lurasidone on weight was - 0.77 kg at the end of the 1-year follow-up. Patients who had received a prior second-generation antipsychotic with medium/high risk for weight gain were estimated to lose an average of 1.68 kg at the end of the 1-year follow-up.

CONCLUSIONS

Lurasidone was associated with a reduction in weight at 1 year following its initiation in patients with schizophrenia or bipolar disorder. Stratified analyses indicated that weight reduction was more pronounced among patients who had received second-generation antipsychotics associated with a higher risk of weight gain prior to lurasidone treatment. These findings are consistent with the results of prior short- and long-term prospective studies and suggest that lurasidone is associated with low risk for weight gain in patients with schizophrenia or bipolar disorder.

Relationship Between Metabolic Syndrome and Clinical Features, and Its Personal-Social Performance in Patients with Schizophrenia

The aim of this study was to evaluate the metabolic syndrome (MS) criteria and also to investigate the effects of MS on medical treatment, clinical course and personal and social performance in patients with schizophrenia. One hundred-sixteen patients with schizophrenia were included in the study. Measurements of MS were calculated in all patients. Brief Psychiatric Rating Scale, Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Personal and Social Performance Scale (PSP) were applied. The frequency of MS according to IDF criteria was 42.2 % among the patients. There was no significant difference between patients with and without MS in terms of age. The ratios of MS were 62.5 % for the group taking typical and atypical antipsychotics together and 35.7 % for the group taking two or more atypical antipsychotics together. The duration of disorder in patients with MS was higher than those without MS. Furthermore there was no significant difference between the schizophrenic patients with and without MS, in terms of PSP scores. Our findings showed that the duration of illness, high scores of BMI, use of clozapine or concurrent use of typical and atypical antipsychotics, depressive and negative symptoms of schizophrenia were significant risk factors for the development of MS.

Etiology of cardiovascular disease in patients with schizophrenia: current perspectives

Cardiovascular morbidity and mortality are important problems among patients with schizophrenia. A wide spectrum of reasons, ranging from genes to the environment, are held responsible for causing the cardiovascular risk factors that may lead to shortening the life expectancy of patients with schizophrenia. Here, we have summarized the etiologic issues related with the cardiovascular risk factors in schizophrenia. First, we focused on heritable factors associated with cardiovascular disease and schizophrenia by mentioning studies about genetics-epigenetics, in the first-episode or drug-naïve patients. In this context, the association and candidate gene studies about metabolic disturbances in schizophrenia are reviewed, and the lack of the effects of epigenetic/posttranscriptional factors such as microRNAs is mentioned. Increased rates of type 2 diabetes mellitus and disrupted metabolic parameters in schizophrenia are forcing clinicians to struggle with metabolic syndrome parameters and related issues, which are also the underlying causes for the risk of having cardiometabolic and cardiovascular etiology. Second, we summarized the findings of metabolic syndrome-related entities and discussed the influence of the illness itself, antipsychotic drug treatment, and the possible disadvantageous lifestyle on the occurrence of metabolic syndrome (MetS) or diabetes mellitus. Third, we emphasized on the risk factors of sudden cardiac death in patients with schizophrenia. We reviewed the findings on the arrhythmias such as QT prolongation, which is a risk factor for Torsade de Pointes and sudden cardiac death or P-wave prolongation that is a risk factor for atrial fibrillation. For example, the use of antipsychotics is an important reason for the prolongation of QT and some other cardiac autonomic dysfunctions. Additionally, we discussed relatively rare issues such as myocarditis and cardiomyopathy, which are important for prognosis in schizophrenia that may have originated from the use of antipsychotic medication. In conclusion, we considered that the studies and awareness about physical needs of patients with schizophrenia are increasing. It seems logical to increase cooperation and shared care between the different health care professionals to screen and treat cardiovascular disease (CVD)-risk factors, MetS, and diabetes in patients with psychiatric disorders, because some risk factors of MetS or CVD are avoidable or at least modifiable to decrease high mortality in schizophrenia. We suggested that future research should focus on conducting an integrated system of studies based on a holistic biopsychosocial evaluation.

Some side effects and effcts on physical activity of second-generation antipsychotics: A study in children and adolescents

Background:

This study was designed to investigate the metabolic adverse effects (AEs) of second-generation antipsychotics (SGAs) and their relationship with physical activity and non-metabolic AE in children and adolescents.

Materials and Methods:

After exclusion of patients with metabolic syndrome, 62 patients (34 children, 28 adolescents) of both genders who were candidates for SGA therapy were selected. Metabolic parameters included fasting blood glucose (FBG), triglyceride (TG), blood pressure (BP), and waist circumference (WC); non-metabolic AEs and physical activity were evaluated at baseline, 1 month, and 3 months after starting the treatment.

Results:

Mean of post-treatment FBG and TG were significantly higher than the baseline values (P < 0.0001). Compared to the baseline value, significantly more patients developed abnormally high (AbH) FBG at the end point (P = 0.02). There was no significant difference in the frequency of patients with AbH-FBG either at the baseline or at the end point (P > 0.05). The frequency of patients with AbH-TG at the end point was not significantly higher than those with baseline AbH-TG (P = 0.10). Although no patient was obese at baseline, 11 (18%) patients developed abdominal obesity at the end point (P < 0.0001). There was no significant difference in the frequency of non-metabolic AE (P > 0.05). There was no significant correlation between metabolic and non-metabolic AE (P > 0.05). Frequency of inactive patients was significantly more than the baseline value (P-0.008), and abdominal obesity was significantly more prevalent in less active participants (P = 0.03).

Conclusion:

The present study showed the AE of SGA on FBG and TG, but no effect on BP and WC. We also found that children are more prone to develop abnormally high FBG.

Breast Cancer Stage and Treatment Among Ohio Medicaid Beneficiaries With and Without Mental Illness

PURPOSE

There is a dearth of studies on cancer outcomes in individuals with mental illness. We compared breast cancer outcomes in Medicaid beneficiaries with and without mental illness.

METHODS

Using records from the 1996 to 2005 Ohio Cancer Incidence Surveillance System (OCISS) and Medicaid files, we identified fee-for-service women age < 65 years diagnosed with incident invasive breast cancer who had enrolled in Medicaid ≥ 3 months before cancer diagnosis (n = 2,177). We retrieved cancer stage, patient demographics, and county of residence from the OCISS. From Medicaid claims data, we identified breast cancer treatment based on procedure codes and mental illness status based on diagnosis codes, prescription drugs dispensed, and service codes. We developed logistic regression models to examine the association between mental illness, cancer stage, and treatment for locoregional disease, adjusting for potential confounders.

RESULTS

Women with mental illness represented 60.2% of the study population. Adjusting for potential confounders, women with mental illness were less likely than those without mental illness to have unstaged or unknown-stage cancer (adjusted odds ratio [OR], 0.61; 95% CI, 0.44 to 0.86; P = .005) or to be diagnosed with distant-stage cancer (adjusted OR, 0.59; 95% CI, 0.40 to 0.85; P = .005). We observed no difference by mental illness status in receipt of definitive treatment (adjusted OR, 1.04; 95% CI, 0.84 to 1.29; P = .08).

CONCLUSION

Among Ohio Medicaid beneficiaries, women with mental illness did not experience disparities in breast cancer stage or treatment of locoregional disease. These findings may reflect the equalizing effects of Medicaid through vulnerable individuals' improved access to both physical and mental health care.

Sedentary behavior and psychiatric symptoms in overweight and obese adults with schizophrenia and schizoaffective disorders (WAIST Study)

OBJECTIVE

Examine the association between sedentary behavior and psychiatric symptoms among overweight and obese adults with schizophrenia or schizoaffective disorders (SZO/SA).

DESIGN

Randomized clinical trial; Weight Assessment and Intervention in Schizophrenia Treatment (WAIST) Study: baseline data collected 2005-2008.

SETTING

University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

PARTICIPANTS

Community-dwelling adults diagnosed with SZO/SA, with mild symptom severity [Positive and Negative Syndrome Scale (PANSS)<90], who were interested in losing weight, age 18-70years, BMI>27kg/m(2).

MEASUREMENTS

Objectively measured sedentary behavior by accelerometry, and psychopathology assessed by PANSS. Participants wore the actigraphs for 7 consecutive days during their waking hours. Sedentary behavior was defined as ≤100 counts per minute during wear-time and excluded sleep and non-wear time.

RESULTS

On average, 81% of the participant's monitoring time or 756min/day was classified as sedentary behavior using accelerometry. No association was observed between sedentary behaviors and PANSS psychiatric symptoms [total (p≥0.75), positive (p≥0.81), negative (p≥0.59) and general psychopathology (p≥0.65) subscales]. No association was observed between sedentary behaviors and age, race, gender and BMI.

CONCLUSION

From a clinical and public health perspective, the amount of time (approximately 13h) and percentage of time (81% excluding non-wear time associated with sleeping) engaged in sedentary behavior among overweight and obese adults in this population is alarming, and points to an urgent need for interventions to decrease sedentary behaviors. The lack of associations between sedentary behavior and psychiatric symptoms may be due to a ceiling effect for sedentary behavior.

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

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Health promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Psychiatric patients have more physical health problems and much shorter life expectancies compared to the general population, due primarily to premature cardiovascular disease. A multi-causal model which includes a higher prevalence of risk factors has provided a valid explanation. It takes into consideration not only risks such as gender, age, and family history that are inherently non-modifiable, but also those such as obesity, smoking, diabetes, hypertension, and dyslipidemia that are modifiable through behavioural changes and improved care. Thus, it is crucial to focus on factors that increase cardiovascular risk. Obesity in particular has been associated with both the lifestyle habits and the side effects of antipsychotic medications. The present systematic review and meta-analysis aims at collecting and updating available evidence on the efficacy of non-pharmacological health promotion programmes for psychotic patients in randomised clinical trials.

METHODS

We systematically reviewed the randomised controlled trials from 1990 onward, in which psychoeducational and/or cognitive-behavioural interventions aimed at weight loss or prevention of weight gain in patients with psychosis had been compared to treatment as usual. We carried out a meta-analysis and pooled the results of the studies with Body Mass Index as primary outcome.

RESULTS

The results of the meta-analysis show an effect toward the experimental group. At the end of the intervention phase there is a -0.98 kg/m(2) reduction in the mean Body Mass Index of psychotic subjects. Notably, prevention studies with individual psychoeducational programmes that include diet and/or physical activity seem to have the highest impact.

CONCLUSIONS

When compared with treatment as usual in psychotic patients, preventive and individual lifestyle interventions that include diet and physical activity generally prove to be effective in reducing weight. Physical screening and monitoring programmes are well accepted by patients and can be implemented in a variety of settings. A weight loss of 0.98 points in the Body Mass Index corresponds to a loss of 3.12% of the initial weight. This percentage is below the 5% to 10% weight loss deemed sufficient to improve weight-related complications such as hypertension, type II diabetes, and dyslipidemia. However, it is reported that outcomes associated with metabolic risk factors may have greater health implications than weight changes alone. Therefore, in addition to weight reduction, the assessment of metabolic parameters to monitor other independent risk factors should also be integrated into physical health promotion and management in people with mental disorders.

Mental illness and use of screening mammography among Medicaid beneficiaries

BACKGROUND

Disparities in receipt of preventive services by people with mental illness have been documented previously. However, whether these disparities extend to screening mammography among individuals experiencing comparable barriers to accessing care has not been examined fully.

PURPOSE

To determine whether disparities exist in receipt of screening mammography between women with and without mental illness enrolled in Medicaid, a program with documented potential to reduce healthcare disparities.

METHODS

Receipt of screening mammography was examined among women aged 50-64 years enrolled in Ohio's Medicaid program during the years 2002-2008 (n=130,088). Receipt of annual screening mammography was examined among those with at least one screening mammography during the study period. Mental illness was identified through diagnostic, service, and pharmacotherapy codes (n=61,661).

RESULTS

Compared to women without mental illness, more women with mental illness received at least one screening mammography during the study period (31.7% vs 38.1%, p<0.001). However, after adjusting for potential confounders, including the presence of comorbid conditions and length of enrollment in Medicaid, women with mental illness were 32% less likely to undergo at least one screening mammography (AOR=0.68, 95% CI=0.66, 0.70). Among those who received at least one screening mammography, fewer women with mental illness received screening mammography on an annual basis (5.9% vs 12.7%, p<0.001; AOR=0.53, 95% CI=0.49, 0.56). For all beneficiaries, each year of enrollment in Medicaid increased the likelihood of screening mammography use by at least 50%.

CONCLUSIONS

Medicaid beneficiaries with mental illness constitute a particularly vulnerable population for suboptimal breast cancer screening.

Dietary habits of patients with schizophrenia: a self-reported questionnaire survey

The present study was carried out to determine the dietary habits of patients with schizophrenia and the influence of these habits on the degree of obesity. The study was developed in a sample of 159 patients, who were given a self-reported questionnaire, to ascertain the influence of socio-familiar aspects, pharmacological treatment, and dietary habits. Anthropometric measurements (body mass index (BMI) and waist circumference (WC)) were also taken. Patients with schizophrenia presented unhealthy dietary habits, as indicated by the finding that 51% of the patients took no longer than 15 min to eat, 40.8% did not eat fruit daily, and 63.1% did not eat fish. Women were three times more likely to be obese than men (odds ratio (OR) = 2.91, P = 0.021). Patients classified as having unhealthy dietary habits have a 2.33-fold higher risk of obesity than patients with good dietary habits (OR = 2.33, P = 0.034). In summary, this paper highlights the fact that patients with schizophrenia have a detrimental dietary pattern that is associated with an increase in BMI and WC, with the consequent development of obesity and related metabolic alterations, regardless of the pharmacological treatment being followed. Future research directions will include exploring the need for nutritional education programmes to improve the dietary habits of such patients.

AVE1625, a cannabinoid CB1 receptor antagonist, as a co-treatment with antipsychotics for schizophrenia: improvement in cognitive function and reduction of antipsychotic-side effects in rodents

RATIONALE

The psychotomimetic effects of cannabis are believed to be mediated via cannabinoid CB1 receptors. Furthermore, studies have implicated CB1 receptors in the pathophysiology of schizophrenia.

OBJECTIVE

These studies investigated the effects of the CB1 receptor antagonist, AVE1625, in acute pharmacological and neurodevelopmental models of schizophrenia. AVE1625 was administered to rodents alone or as a co-treatment with clinically used antipsychotic drugs (APDs).

METHODS

The antipsychotic potential of AVE1625 was tested using psychotomimetic-induced hyperactivity and latent inhibition (LI) deficit models. The procognitive profile was assessed using hole board, novel object recognition, auditory evoked potential, and LI techniques. In addition, the side-effect profile was established by measuring catalepsy, antipsychotic-induced weight gain, plasma levels of prolactin, and anxiogenic potential.

RESULTS

AVE1625 (1, 3, and 10 mg/kg ip), reversed abnormally persistent LI induced by MK-801 or neonatal nitric oxide synthase inhibition in rodents, and improved both working and episodic memory. AVE1625 was not active in positive symptom models but importantly, it did not diminish the efficacy of APDs. It also decreased catalepsy and weight gain induced by APDs, suggesting that it may decrease APD-induced extrapyramidal side effects (EPS) and compliance. Unlike other CB1 antagonists, AVE1625 did not produce anxiogenic-like effects.

CONCLUSIONS

These preclinical data suggest that AVE1625 may be useful to treat the cognitive deficits in schizophrenia and as a co-treatment with currently available antipsychotics. In addition, an improved side-effect profile was seen, with potential to ameliorate the EPS and weight gain issues with currently available treatments.

Metabolic syndrome and psychiatrists' choice of follow-up interventions in patients treated with atypical antipsychotics in Denmark and Sweden

INTRODUCTION

The aim of the present study was to obtain point prevalence estimates of the metabolic syndrome according to the NCEP III criteria in a sample of patients with schizophrenia spectrum disorders treated with atypical antipsychotic drugs in Denmark and Sweden, and to assess the psychiatrists' choice of recommendations for follow-up interventions based on the patients' laboratory results.

METHOD

This was a cross-sectional, observational multi-center study in Denmark and Sweden, in consecutively screened in- and outpatients with schizophrenia spectrum disorders and continuously treated for at least 3 months with atypical antipsychotic drugs.

RESULTS

The metabolic syndrome as per medical history was present in 1% of 582 evaluable patients at baseline. After performing laboratory measurements and applying the NCEP III criteria, metabolic syndrome was confirmed in 43% of subjects. The high rate of metabolic syndrome did not elicit much decisive action on the part of the treating psychiatrists; the most frequent action taken was dietary and exercise advice (in 75% of subjects), while in 54% and 19% of subjects a laboratory follow-up and blood pressure follow-up were advised respectively. Change of antipsychotic medication was recommended in only 10% of patients, and in further 11% of patients, no action was taken.

CONCLUSION

Observed metabolic syndrome prevalence rates were at least twice the rates observed in a normal, non-diabetic population. It appears that in this vulnerable population of patients with schizophrenia spectrum disorders, metabolic syndrome remains underdiagnosed and undertreated.

WAY-163909, a 5-HT2C agonist, enhances the preclinical potency of current antipsychotics

INTRODUCTION

5-HT(2C) agonists, by decreasing mesolimbic dopamine without affecting nigrostriatal dopamine, are predicted to have antipsychotic efficacy with low extrapyramidal side effects (EPS). Combining 5-HT(2C) agonists with low doses of existing antipsychotics could increase treatment efficacy while reducing treatment liabilities such as EPS (typical antipsychotics), and the propensity for weight gain (atypical antipsychotics).

OBJECTIVES

The objectives of these studies were to combine WAY-163909, a selective 5-HT(2C) agonist, with either the typical antipsychotic haloperidol, or the atypical antipsychotic clozapine, at doses that were ineffective on their own, with the expectation that a shift in potency in several rodent behavior models predictive of antipsychotic activity would occur.

RESULTS AND DISCUSSION

In mice, co-administration of either haloperidol, or clozapine, produced a significant leftward shift in the ability of WAY-163909 to block apomorphine-induced climbing behavior, without any affect on apomorphine-induced stereotypy or an increased propensity for catalepsy. In the rat-conditioned avoidance model, WAY-163909 was combined with either haloperidol or clozapine at doses that individually produced reductions in avoidance response on the order of 10%, while the combination of WAY-163909 and either of the antipsychotics resulted in a greater than 70% reduction in avoidance, with no evidence of response failures, or pharmacokinetic interaction.

CONCLUSION

Doses of either haloperidol or clozapine, that failed to antagonize an MK-801 induced deficit in prepulse inhibition, significantly attenuated the sensory gating deficit when combined with WAY-163909. Data support the notion that 5-HT(2C) receptor agonists, co-administered with other marketed antipsychotics, allow for dose sparing with a more favorable side-effect profile.

'Mind and Body': a lifestyle programme for people on antipsychotic medication

RATIONALE

Psychiatric illnesses such as schizophrenia and their treatments have consequences in terms of lifestyle, diet and weight.

AIMS AND OBJECTIVES

'Mind and Body' is a 10-week programme of weekly sessions aimed to improve the health status of people treated with second generation antipsychotic medications.

METHODS

The programme focuses on a range of lifestyle strategies including diet and exercise and was conducted at a Community Health Centre by professionally qualified staff. Between 2002 and 2006, 50 participants enrolled in, and 30 completed the programme. Measures of body weight, health status (Short Form-36) and blood markets (plasma glucose, haemoglobin A1c and lipid profile) were collected at commencement and completion of the programme. Results A modest improvement was demonstrated in mean values for the majority of measures collected.

CONCLUSIONS

A lifestyle program for people treated with antipsychotic medications is achievable and may be worthwhile although gains may be modest.

A 24-week, multicenter, open-label, randomized study to compare changes in glucose metabolism in patients with schizophrenia receiving treatment with olanzapine, quetiapine, or risperidone

OBJECTIVE

This randomized, 24-week, flexible-dose study compared changes in glucose metabolism in patients with DSM-IV schizophrenia receiving initial exposure to olanzapine, quetiapine, or risperidone.

METHOD

The hypothesized primary endpoint was change (baseline to week 24) in area under the curve (AUC) 0- to 2-hour plasma glucose values during an oral glucose tolerance test (OGTT); primary analysis: olanzapine versus quetiapine. Secondary endpoints included mean change in AUC 0- to 2-hour plasma insulin values, insulin sensitivity index, and fasting lipids. The first patient enrolled on April 29, 2004, and the last patient completed the study on October 24, 2005.

RESULTS

Mean weight change (kg) over 24 weeks was +3.7 (quetiapine), +4.6 (olanzapine), and +3.6 (risperidone). Based on data from 395 patients (quetiapine, N = 115 [mean dose = 607.0 mg/day], olanzapine, N = 146 [mean dose = 15.2 mg/day], and risperidone, N = 134 [mean dose = 5.2 mg/day]), mean change in AUC 0- to 2-hour glucose value (mg/dL x h) at week 24 was significantly lower for quetiapine versus olanzapine (t = 1.98, df = 377, p = .048). Increases in AUC 0- to 2-hour glucose values were statistically significant with olanzapine (+21.9 mg/dL x h, 95% CI = 11.5 to 32.4 mg/dL x h) and risperidone (+18.8 mg/dL x h, 95% CI = 8.1 to 29.4 mg/dL x h), but not quetiapine (+9.1 mg/dL x h, 95% CI = -2.3 to 20.5 mg/dL x h). AUC 0- to 2-hour insulin values increased statistically significantly with olanzapine (+24.5%, 95% CI = 11.5% to 39.0%), but not with quetiapine or risperidone. Reductions in insulin sensitivity index were statistically significant with olanzapine (-19.1%, 95% CI = -27.9% to -9.3%) and risperidone (-15.8%, 95% CI = -25.1% to -5.4%), but not quetiapine. Total cholesterol and low-density lipoprotein levels increased statistically significantly with olanzapine (+21.1 mg/dL, 95% CI = 13.0 to 29.2 mg/dL, and +20.5 mg/dL, 95% CI = 13.8 to 27.1 mg/dL, respectively) and quetiapine (+13.1 mg/dL, 95% CI = 4.3 to 21.9 mg/dL, and +13.3 mg/dL, 95% CI = 6.1 to 20.5 mg/dL, respectively), but not risperidone. Statistically significant increases in triglycerides (+30.9 mg/dL, 95% CI = 10.9 to 51.0 mg/dL), total cholesterol/high-density lipoprotein (HDL) ratio (0.5, 95% CI = 0.2 to 0.8), and triglyceride/HDL ratio (0.3, 95% CI = 0.0 to 0.6) were observed with olanzapine only.

CONCLUSION

The results indicate a significant difference in the change in glucose tolerance during 6 months' treatment with olanzapine versus quetiapine, with significant reductions on olanzapine and risperidone, but not quetiapine; these differential changes were largely explained by changes in insulin sensitivity.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00214578.

Obesity in schizophrenia: screening, monitoring, and health promotion

PURPOSE

This paper reviews risks, assessments, antipsychotic medication choices, and lifestyle interventions for obesity in persons with schizophrenia.

CONCLUSIONS

Antipsychotic medication is the most important treatment choice. Simple diet teaching must take into account the cognitive limitations of clients with schizophrenia. After medical clearance is obtained, moderate exercise can be encouraged. Education about exercise benefits may increase motivation.

PRACTICE IMPLICATIONS

Nurses would be remiss to ignore the physical health effects of obesity in schizophrenia. Practitioners must choose psychiatric medications and provide health education, health promotion, and appropriate referrals to optimize quality of life for this group.

Differential metabolic effects of antipsychotic treatments

Metabolic abnormalities such as obesity, diabetes and dyslipidaemia increase the risk of cardiovascular disease, as well as a number of other adverse long-term health consequences. There is increasing evidence from case studies, retrospective analyses and clinical trials to suggest that second-generation antipsychotics can increase the risk of metabolic abnormalities in patients with schizophrenia, with indications that the level of risk may vary among antipsychotic medications. Comparison of weight gain data for the second-generation antipsychotics provides strong evidence to indicate differences in the weight gain liability, with clozapine and olanzapine being associated with the greatest weight gain over 1 year. Data suggest that these treatment-induced changes in weight are primarily responsible for treatment-related changes in glucose metabolism; however, there is also evidence to suggest that some impairments in glucose metabolism may be independent of adiposity. Studies investigating the effects of atypical antipsychotics on glucose metabolism have used a number of techniques of varying sensitivity and quality in an attempt to assign causality. Recent studies using gold standard methodologies, for both insulin sensitivity and adiposity, have shown that psychiatric patients receiving antipsychotics are at least as sensitive to the adverse effects of adiposity on glucose and lipid metabolism as non-psychiatric controls. This demonstrates the importance of weight gain prevention in psychiatry to help reduce long-term risk. There is also growing evidence to suggest that the differential effects of second-generation antipsychotics on metabolic parameters also result in differences in the risk of metabolic syndrome, with olanzapine having a significantly higher risk than either aripiprazole or ziprasidone. This differential risk highlights the need for adequate monitoring in patients receiving treatment with second-generation antipsychotics and careful selection of treatment in high-risk patients.