Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness

The neglected association between schizophrenia and bone fragility: a systematic review and meta-analyses

Schizophrenia is associated with increased risk of medical comorbidity, possibly including osteoporosis, which is a public health concern due to its significant social and health consequences. In this systematic review and meta-analysis, we aimed to determine whether schizophrenia is associated with bone fragility. The protocol for this review has been registered with PROSPERO (CRD42020171959). The research question and inclusion/exclusion criteria were developed and presented according to the PECO (Population, Exposure, Comparison, Outcome) framework. Schizophrenia was identified from medical records, DSM-IV/5 or the ICD. The outcomes for this review were bone fragility [i.e., bone mineral density (BMD), fracture, bone turnover markers, bone quality]. A search strategy was developed and implemented for the electronic databases. A narrative synthesis was undertaken for all included studies; the results from eligible studies reporting on BMD and fracture were pooled using a random effects model to complete a meta-analysis. The conduct of the review and reporting of results adhered to PRISMA guidelines. Our search yielded 3103 studies, of which 29 met the predetermined eligibility criteria. Thirty-seven reports from 29 studies constituted 17 studies investigating BMD, eight investigating fracture, three investigating bone quality and nine investigating bone turnover markers. The meta-analyses revealed that people with schizophrenia had lower BMD at the lumbar spine [standardised mean difference (SMD) -0.74, 95% CI -1.27, -0.20; Z = -2.71, p = 0.01] and at the femoral neck (SMD -0.78, 95% CI -1.03, -0.53; Z = -6.18, p ≤ 0.001). Also observed was a higher risk of fracture (OR 1.43, 95% CI 1.27, 1.61; Z = 5.88, p ≤ 0.001). Following adjustment for publication bias, the association between schizophrenia and femoral neck BMD (SMD -0.63, 95% CI -0.97, -0.29) and fracture (OR 1.32, 95% CI 1.28, 1.35) remained. Significantly increased risk of bone fragility was observed in people with schizophrenia. This association was independent of sex, participant number, methodological quality and year of publication.

Body mass index, smoking behavior, and depression mediated the effects of schizophrenia on chronic obstructive pulmonary disease: trans-ethnic Mendelian-randomization analysis

Background

Previous studies have highlighted the association between schizophrenia (SCZ) and chronic obstructive pulmonary disease (COPD), yet the causal relationship remains unestablished.

Methods

Under the genome-wide significance threshold (P<5×10-8), data from individuals of European (EUR) and East Asian (EAS) ancestries with SCZ were selected for analysis. Univariable Mendelian randomization (MR) explored the causal relationship between SCZ and COPD. Linkage disequilibrium score (LDSC) regression was used to calculate genetic correlation, while multivariable and mediation MR further investigated the roles of six confounding factors and their mediating effects. The primary method utilized was inverse-variance weighted (IVW), complemented by a series of sensitivity analyses and false discovery rate (FDR) correction.

Results

LDSC analysis revealed a significant genetic correlation between SCZ and COPD within EUR ancestry (rg = 0.141, P = 6.16×10-7), with no such correlation found in EAS ancestry. IVW indicated a significant causal relationship between SCZ and COPD in EUR ancestry (OR = 1.042, 95% CI 1.013-1.071, P = 0.003, PFDR = 0.015). Additionally, replication datasets provide evidence of consistent causal associations(P < 0.05 & PFDR < 0.05). Multivariable and mediation MR analyses identified body mass index (BMI)(Mediation effect: 50.57%, P = 0.02), age of smoking initiation (Mediation effect: 27.42%, P = 0.02), and major depressive disorder (MDD) (Mediation effect: 60.45%, P = 6.98×10-5) as partial mediators of this causal relationship. No causal associations were observed in EAS (OR = 0.971, 95% CI 0.875-1.073, P = 0.571, PFDR = 0.761) ancestry. No causal associations were found in the reverse analysis across the four ancestries (P > 0.05 & PFDR > 0.05).

Conclusions

This study confirmed a causal relationship between SCZ and the risk of COPD in EUR ancestry, with BMI, smoking, and MDD serving as key mediators. Future research on a larger scale is necessary to validate the generalizability of these findings across other ancestries.

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Real-world predictors of relapse in patients with schizophrenia and schizoaffective disorder in a large health system

Schizophrenia is often characterized by recurring relapses, which are associated with a substantial clinical and economic burden. Early identification of individuals at the highest risk for relapse in real-world treatment settings could help improve outcomes and reduce healthcare costs. Prior work has identified a few consistent predictors of relapse in schizophrenia, however, studies to date have been limited to insurance claims data or small patient populations. Thus, this study used a large sample of health systems electronic health record (EHR) data to analyze relationships between patient-level factors and relapse and model a set of factors that can be used to identify the increased prevalence of relapse, a severe and preventable reality of schizophrenia. This retrospective, observational cohort study utilized EHR data extracted from the largest Midwestern U.S. non-profit healthcare system to identify predictors of relapse. The study included patients with a diagnosis of schizophrenia (ICD-10 F20) or schizoaffective disorder (ICD-10 F25) who were treated within the system between October 15, 2016, and December 31, 2021, and received care for at least 12 months. A relapse episode was defined as an emergency room or inpatient encounter with a pre-determined behavioral health-related ICD code. Patients' baseline characteristics, comorbidities and healthcare utilization were described. Modified log-Poisson regression (i.e. log Poisson regression with a robust variance estimation) analyses were utilized to estimate the prevalence of relapse across patient characteristics, comorbidities and healthcare utilization and to ultimately identify an adjusted model predicting relapse. Among the 8119 unique patients included in the study, 2478 (30.52%) experienced relapse and 5641 (69.48%) experienced no relapse. Patients were primarily male (54.72%), White Non-Hispanic or Latino (54.23%), with Medicare insurance (51.40%), and had baseline diagnoses of substance use (19.24%), overweight/obesity/weight gain (13.06%), extrapyramidal symptoms (48.00%), lipid metabolism disorder (30.66%), hypertension (26.85%), and diabetes (19.08%). Many differences in patient characteristics, baseline comorbidities, and utilization were revealed between patients who relapsed and patients who did not relapse. Through model building, the final adjusted model with all significant predictors of relapse included the following variables: insurance, age, race/ethnicity, substance use diagnosis, extrapyramidal symptoms, number of emergency room encounters, behavioral health inpatient encounters, prior relapses episodes, and long-acting injectable prescriptions written. Prevention of relapse is a priority in schizophrenia care. Challenges related to historical health record data have limited the knowledge of real-world predictors of relapse. This study offers a set of variables that could conceivably be used to construct algorithms or models to proactively monitor demographic, comorbidity, medication, and healthcare utilization parameters which place patients at risk for relapse and to modify approaches to care to avoid future relapse.

Network-based analysis on the genes and their interactions reveals link between schizophrenia and Alzheimer's disease

Schizophrenia (SCZ) is a heterogeneous psychiatric disorder marked by impaired thinking, emotions, and behaviors. Studies have suggested a strong connection between SCZ and Alzheimer's disease (AD), however, controversies exist and the underlying mechanisms linking these two disorders remain largely unknown. Therefore, systematic studies of SCZ- and AD-related genes will provide valuable insights into the molecular features of these two diseases and their comorbidities. In this study, we obtained 331 SCZ-related genes, 650 AD-related genes, 65 shared genes between SCZ and AD. Enrichment analysis shown that these 65 shared genes were mainly involved in cognition, neural development, synaptic transmission, drug reactions, metabolic processes and immune related processes, suggesting a complex mechanism for the co-existence of SCZ and AD. In addition, we performed pathway enrichment analysis and found a total of 57 common pathways between SCZ and AD, which could be largely grouped into three modules: immune module, neurodevelopment module and cancer module. We eventually identified the potential disease-related genes whose interactions provide clues to the overlapping symptoms between SCZ and AD.

Associations between Social Adversities and Chronic Medical Conditions in a Statewide Sample of Individuals in Treatment for Mental Illnesses

Individuals with mental illnesses experience disproportionately high rates of social adversities, chronic medical conditions, and early mortality. We analyzed a large, statewide dataset to explore associations between four social adversities and the presence of one or more, and then two or more, chronic medical conditions among individuals in treatment for mental illnesses in New York State. In Poisson regression models adjusting for multiple covariates (e.g., gender, age, smoking status, alcohol use), the presence of one or more adversities was associated with the presence of at least one medical condition (prevalence ratio (PR) = 1.21) or two or more medical conditions (PR = 1.46), and two or more adversities was associated with at least one medical condition (PR = 1.25) or two or more medical conditions (PR = 1.52) (all significant at p < .0001). Greater attention to primary, secondary, and tertiary prevention of chronic medical conditions is needed in mental health treatment settings, especially among those experiencing social adversities.

Depression and Differential Oral Health Status Among U.S. Adults With and Without Prior Active Duty Service in the U.S. Military, National Health and Nutrition Examination Survey 2011-2018

INTRODUCTION

Veterans suffer from lower overall well-being than non-veterans because of their unique life course. This study aims to compare the impact of depression on oral health for veteran and non-veteran populations.

MATERIALS AND METHODS

Data from 11,693 adults (18+) participating in the National Health and Nutrition Examination Survey (2011-2018) were analyzed. The outcome variables were dichotomous (at/above mean) decayed, missing, and filled teeth due to caries (DMFT), as well as the components, namely, missing teeth, filled teeth (FT), and decayed teeth (DT). The primary predictor variable combined depression screening outcome and veteran status (veteran/depressed, veteran/not depressed, non-veteran/depressed, and non-veteran/not depressed). Covariates included socioeconomic factors, demographics, wellness factors, and oral health-related habits. Associations between outcome and predictor variables were assessed with a fully adjusted logistic regression analysis.

RESULTS

Veterans, regardless of depression status, had more DMFT, FT, missing teeth, and DT compared to non-veterans. After controlling for covariates, veterans suffering from depression had higher odds of DT (1.5, 95% CI, 1.0-2.4) compared to non-veterans without depression. In general, veterans who screened negative for depression had better oral health compared to all groups, with lower odds of DT (0.7, 95% CI, 0.6-0.9) and higher odds of FT (1.4, 95% CI, 1.1-1.7) compared to non-veterans with and without depression.

CONCLUSIONS

This study found that not only veterans have higher odds of overall caries experience, but also veterans suffering from depression have higher odds of active caries compared to non-depressed veterans. Most veterans lack Veterans Health Administration dental benefits and face challenges maintaining oral health on top of medical and mental health burdens. Our results add further urgency to increasing dental care access for this vulnerable population because of the exacerbation of unmet oral health care needs attributable to the additional mental health challenges veterans face.

COVID-19-Related Outcomes Among Group Home Residents with Serious Mental Illness in Massachusetts in the First Year of the Pandemic

This study examined COVID-19 infection and hospitalizations among people with serious mental illness who resided in residential care group homes in Massachusetts during the first year of the COVID-19 pandemic. The authors analyzed data on 2261 group home residents and COVID-19 data from the Massachusetts Department of Public Health. Outcomes included positive COVID-19 tests and COVID-19 hospitalizations March 1, 2020-June 30, 2020 (wave 1) and July 1, 2020-March 31, 2021 (wave 2). Associations between hazard of outcomes and resident and group home characteristics were estimated using multi-level Cox frailty models including home- and city-level frailties. Between March 2020 and March 2021, 182 (8%) residents tested positive for COVID-19, and 51 (2%) had a COVID-19 hospitalization. Compared with the Massachusetts population, group home residents had age-adjusted rate ratios of 3.0 (4.86 vs. 1.60 per 100) for COVID infection and 13.5 (1.99 vs. 0.15 per 100) for COVID hospitalizations during wave 1; during wave 2, the rate ratios were 0.5 (4.55 vs. 8.48 per 100) and 1.7 (0.69 vs. 0.40 per 100). In Cox models, residents in homes with more beds, higher staff-to-resident ratios, recent infections among staff and other residents, and in cities with high community transmission risk had greater hazard of COVID-19 infection. Policies and interventions that target group home-specific risks are needed to mitigate adverse communicable disease outcomes in this population.Clinical Trial Registration Number This study provides baseline (i.e., pre-randomization) data from a clinical trial study NCT04726371.

The Effects of a Digital, Transdiagnostic, Clinically and Peer-Moderated Treatment Platform for Young People With Emerging Mental Health Complaints: Repeated Measures Within-Subjects Study

BACKGROUND

To address the growing prevalence of youth mental health problems, early intervention is crucial to minimize individual, societal, and economic impacts. Indicative prevention aims to target emerging mental health complaints before the onset of a full-blown disorder. When intervening at this early stage, individuals are more responsive to treatment, resulting in cost-effective outcomes. The Moderated Online Social Therapy platform, which was successfully implemented and proven effective in Australia, is a digital, peer- and clinically moderated treatment platform designed for young people. The Netherlands was the first country outside Australia to implement this platform, under the name Engage Young People Early (ENYOY). It has the potential to reduce the likelihood of young people developing serious mental health disorders.

OBJECTIVE

This study aims to investigate the effects on young people using the ENYOY-platform in relation to psychological distress, psychosocial functioning, and positive health parameters.

METHODS

Dutch-speaking young people with emerging mental health complaints (N=131) participated in the ENYOY-platform for 6 months in a repeated measures within-subjects study. Psychological distress, psychosocial functioning, and positive health parameters were assessed at baseline and 3, 6, and 12 months. Repeated measures ANOVA was conducted and adjusted for age, sex, therapy, and community activity. The Reliable Change Index and Clinically Significant Index were computed to compare the baseline with the 6- and 12-month measurements. The missing data rate was 22.54% and the dropout rate 62.6% (82/131).

RESULTS

The primary analysis (77/131, 58.8%) showed that psychological distress decreased and psychosocial functioning improved over time with large effect sizes (P<.001 in both cases; ηp2=0.239 and 0.318, respectively) independent of age (P=.76 for psychological distress and P=.48 for psychosocial functioning), sex (P=.24 and P=.88, respectively), therapy activity (P=.49 and P=.80, respectively), or community activity (P=.59 and P=.48, respectively). Similarly, secondary analyses (51/131, 38.9%) showed significant effects of time on the quality of life, well-being, and meaningfulness positive health parameters (P<.05; ηp2=0.062, 0.140, and 0.121, respectively). Improvements in all outcome measures were found between baseline and 3 and 6 months (P≤.001-.01; d=0.23-0.62) and sustained at follow-up (P=.18-.97; d=0.01-0.16). The Reliable Change Index indicated psychological distress improvements in 38% (39/102) of cases, no change in 54.9% (56/102) of cases, and worsening in 5.9% (6/102) of cases. Regarding psychosocial functioning, the percentages were 50% (51/102), 43.1% (44/102), and 6.9% (7/102), respectively. The Clinically Significant Index demonstrated clinically significant changes in 75.5% (77/102) of cases for distress and 89.2% (91/102) for functioning.

CONCLUSIONS

This trial demonstrated that the ENYOY-platform holds promise as a transdiagnostic intervention for addressing emerging mental health complaints among young people in the Netherlands and laid the groundwork for further clinical research. It would be of great relevance to expand the population on and service delivery of the platform.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-021-03315-x.

A Systematic Review on the Association between Schizophrenia and Bipolar Disorder with Chronic Obstructive Pulmonary Disease

A systematic review aimed to investigate the association between schizophrenia and bipolar disorder and chronic obstructive pulmonary disease (COPD), its prevalence and incidence, potential factors associated with its occurrence and its impact on mortality among these patients. We performed the literature search in PubMed, Scopus and PsycInfo from inception to February 2022 and identified 19 studies: ten cross-sectional, 5 that included cross-sectional and longitudinal analyses, and 4 retrospective cohort studies. The reported prevalence of COPD ranged from 2.6% to 52.7% in patients with schizophrenia and between 3.0% and 12.9% in patients with bipolar disorder. Two studies reported an annual incidence of COPD of 2.21 cases/100 person-years in patients with schizophrenia and 2.03 cases/100 person-years in patients with bipolar disorder. Among the risk factors evaluated in three studies, only advanced age was consistently associated with the presence/occurrence of COPD in patients with schizophrenia and bipolar disorder; the role of tobacco consumption was not investigated in those three studies. According to two studies, the likelihood of mortality from COPD showed an over 3-fold increase in patients with schizophrenia and a 2-fold increase in those with bipolar disorder compared to the overall population; COPD was also associated with increased inpatient mortality. Available data indicate that COPD in patients with schizophrenia and bipolar disorder is a major public health problem. National and international health organizations should strive to specifically address this issue by creating awareness about this health problem and developing specific programs for screening and early intervention aimed to reduce the burden of COPD in these populations.

Patient characteristics associated with the successful transition to virtual care: Lessons learned from the first million patients

INTRODUCTION

The increased use of telehealth to maintain ambulatory care during the COVID-19 pandemic had potential to exacerbate or diminish disparities in access to care.

OBJECTIVE

The purpose of this study was to describe patient characteristics associated with successful transition from in-person to virtual care, and video vs audio-only participation.

METHODS

This was a retrospective analysis of electronic health record data from all patients with ambulatory visits from 1 October 2019-30 September 2020 in a large integrated health system in the Northeast USA. The outcome of interest was receipt of virtual care, and video vs audio-only participation. We matched home addresses with census-tract level area social vulnerability index (SVI) and Internet access. Among ambulatory care patients, we used logistic regression to identify characteristics associated with virtual participation. Among virtual participants, we identified characteristics associated with video vs audio-only visits.

RESULTS

Among 1,241,313 patients, 528,542 (42.6%) were virtual participants. Relative to in-person only, virtual participants were older, more often English-proficient and with activated patient portal. Characteristics associated with virtual participation included patients with: only behavioural health visits, COVID patients, highest quartile of visit frequency, and multiple visit types. Characteristics associated with video participation (relative to audio-only) included being younger and patients with: only behavioural health visits, highest quartile of visit frequency, non-Hispanic black race, limited English proficiency and inactivated portal account.

DISCUSSION

In our regional healthcare system, the transition to virtual care during COVID was vital for continued access to care, but substantial inequity remained. Without audio-only visits, access to care would have been even more limited for our most vulnerable patients.

How African Americans With Severe Mental Illness and Trauma Experience Diet and Exercise

African Americans have a higher prevalence of obesity and obesity-related diseases than other racial/ethnic groups; among persons with serious mental illness (SMI), African Americans fare worse as well. This qualitative study focused on the perceptions of African Americans with SMI in regard to 1) their experiences with diet and exercise behaviors post trauma and 2) how diet and exercise programming can address trauma. A community-based participatory research (CBPR) team developed the interview guide, research protocols, and conducted three focus groups. The team used thematic analysis to analyze the data. Participant (N = 27) responses on the experience of trauma were coded into the following themes: 1) emotional eating, 2) appetite loss, 3) hesitancy to exercise due to community violence, 4) staying home due to mental health symptoms, and 5) substance use. Themes around how programming can address trauma included: 1) support, 2) communication, 3) strategies to avoid trauma, and 4) engagement in programming. Findings suggest the need for human service professionals to infuse trauma-informed communications and practices throughout programming, incorporate peer-led services and address concerns related to community violence.

Updated strategies for the management of poor medication adherence in patients with bipolar disorder

INTRODUCTION

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

AREAS COVERED

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

EXPERT OPINION

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

Medicaid reimbursement rates for primary care services and behavioral health outcomes

We study the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes-defined here as mental illness and substance use disorders. Medicaid enrollees are at elevated risk for these, and other, chronic conditions and are likely to have unmet treatment needs. We apply two-way fixed-effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010-2016. We find that higher primary care reimbursement rates reduce mental illness and substance use disorders among non-elderly adult Medicaid enrollees, although we interpret findings for substance use disorders with some caution as they may be vulnerable to differential pre-trends. Overall, our findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.

Designing Practical Motivational Interviewing Training for Mental Health Practitioners Implementing Behavioral Lifestyle Interventions: Protocol for 3 Pilot Intervention Studies

BACKGROUND

Motivational interviewing (MI) is an evidence-based, patient-centered communication method shown to be effective in helping persons with serious mental illness (SMI) to improve health behaviors. In clinical trials where study staff conducted lifestyle interventions incorporating an MI approach, cardiovascular disease (CVD) risk profiles of participants with SMI showed improvement. Given the disproportionate burden of CVD in this population, practitioners who provide somatic and mental health care to persons with SMI are ideally positioned to deliver patient-centered CVD risk reduction interventions. However, the time for MI training (traditionally 16-24 hours), follow-up feedback, and the coaching required to develop and maintain patient-centered skills are significant barriers to incorporating MI when scaling up these evidence-based practices.

OBJECTIVE

We describe the design and development of the following 2 scalable MI training approaches for community mental health practitioners: real-time brief workshops and follow-up asynchronous avatar training. These approaches are being used in 3 different pilot implementation research projects that address weight loss, smoking cessation, and CVD risk reduction in people with SMI who are a part of ALACRITY Center, a research-to-practice translation center funded by the National Institute of Mental Health.

METHODS

Clinicians and staff in community mental health clinics across Maryland were trained to deliver 3 distinct evidence-based physical health lifestyle interventions using an MI approach to persons with SMI. The real-time brief MI workshop training for ACHIEVE-D weight loss coaches was 4 hours; IMPACT smoking cessation counselors received 2-hour workshops and prescribers received 1-hour workshops; and RHYTHM CVD risk reduction program staff received 4 hours of MI. All workshop trainings occurred over videoconference. The asynchronous avatar training includes 1 common didactic instructional module for the 3 projects and 1 conversation simulation unique to each study's target behavior. Avatar training is accessible on a commercial website. We plan to assess practitioners' attitudes and beliefs about MI and evaluate the impact of the 2 MI training approaches on their MI skills 3, 6, and 12 months after training using the MI Treatment Integrity 4.2.1 coding tool and the data generated by the avatar-automated scoring system.

RESULTS

The ALACRITY Center was funded in August 2018. We have implemented the MI training for 126 practitioners who are currently delivering the 3 implementation projects. We expect the studies to be complete in May 2023.

CONCLUSIONS

This study will contribute to knowledge about the effect of brief real-time training augmented with avatar skills practice on clinician MI skills. If MI Treatment Integrity scoring shows it to be effective, brief videoconference trainings supplemented with avatar skills practice could be used to train busy community mental health practitioners to use an MI approach when implementing physical health interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44830.

Best practices to reduce COVID-19 in group homes for individuals with serious mental illness and intellectual and developmental disabilities: Protocol for a hybrid type 1 effectiveness-implementation cluster randomized trial

BACKGROUND

People with serious mental illness (SMI) and intellectual disabilities and/or developmental disabilities (ID/DD) living in group homes (GHs) and residential staff are at higher risk for COVID-19 infection, hospitalization, and death compared with the general population.

METHODS

We describe a hybrid type 1 effectiveness-implementation cluster randomized trial to assess evidence-based infection prevention practices to prevent COVID-19 for residents with SMI or ID/DD and the staff in GHs. The trial will use a cluster randomized design in 400 state-funded GHs in Massachusetts for adults with SMI or ID/DD to compare effectiveness and implementation of "Tailored Best Practices" (TBP) consisting of evidence-based COVID-19 infection prevention practices adapted for residents with SMI and ID/DD and GH staff; to "General Best Practices" (GBP), consisting of required standard of care reflecting state and federal standard general guidelines for COVID-19 prevention in GHs. External (i.e., community-based research staff) and internal (i.e., GH staff leadership) personnel will facilitate implementation of TBP. The primary effectiveness outcome is incident SARS-CoV-2 infection and secondary effectiveness outcomes include COVID-19-related hospitalizations and mortality in GHs. The primary implementation outcomes are fidelity to TBP and rates of COVID-19 vaccination. Secondary implementation outcomes are adoption, adaptation, reach, and maintenance. Outcomes will be assessed at baseline, 3-, 6-, 9-, 12-, and 15-months post-randomization.

CONCLUSIONS

This study will advance knowledge on comparative effectiveness and implementation of two different strategies to prevent COVID-19-related infection, morbidity, and mortality and promote fidelity and adoption of these interventions in high-risk GHs for residents with SMI or ID/DD and staff.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04726371.

Mortality in people with mental disorders in Poland: A nationwide, register-based cohort study

BACKGROUND

Mortality among people with mental disorders is higher in comparison with the general population. There is a scarcity of studies on mortality in the abovementioned group of people in Central and Eastern European countries.

METHODS

The study aimed to assess all-cause mortality in people with mental disorders in Poland. We conducted a nationwide, register-based cohort study utilizing data from two nationwide registries in Poland: the registry of healthcare services reported to the National Health Fund (2009-2018) and the all-cause death registry from Statistics Poland (2019). We identified individuals who were consulted or hospitalized in public mental healthcare facilities and received at least one diagnosis of mental disorders (International Statistical Classification of Diseases and Health Problems [ICD-10]) from 2009 to 2018. Standardized mortality ratios (SMRs) were compared between people with a history of mental disorder and the general population.

RESULTS

The study comprised 4,038,517 people. The SMR for individuals with any mental disorder compared with the general population was 1.54. SMRs varied across diagnostic groups, with the highest values for substance use disorders (3.04; 95% CI 3.00-3.09), schizophrenia, schizotypal and delusional disorders (2.12; 95% CI 2.06-2.18), and pervasive and specific developmental disorders (1.68; 95% CI 1.08-2.29). When only inpatients were considered, all-cause mortality risk was almost threefold higher than in the general population (SMR 2.90; 95% CI 2.86-2.94).

CONCLUSIONS

In Poland, mortality in people with mental disorders is significantly higher than in the general population. The results provide a reference point for future longitudinal studies on mortality in Poland.

Colorectal cancer treatment in people with severe mental illness: a systematic review and meta-analysis

AIMS

People with severe mental illness (SMI) have a greater risk of dying from colorectal cancer (CRC), even though the incidence is lower or similar to that of the general population This pattern is unlikely to be solely explained by lifestyle factors, while the role of differences in cancer healthcare access or treatment is uncertain.

METHODS

We undertook a systematic review and meta-analysis on access to guideline-appropriate care following CRC diagnosis in people with SMI including the receipt of surgery, chemo- or radiotherapy. We searched for full-text articles indexed by PubMed, EMBASE, PsychInfo and CINAHL that compared CRC treatment in those with and without pre-existing SMI (schizophrenia, schizoaffective, bipolar and major affective disorders). Designs included cohort or population-based case-control designs.

RESULTS

There were ten studies (sample size = 3501-591 561). People with SMI had a reduced likelihood of surgery (RR = 0.90, 95% CI 0.92-0.97; p = 0.005; k = 4). Meta-analyses were not possible for the other outcomes but in results from individual studies, people with SMI were less likely to receive radiotherapy, chemotherapy or sphincter-sparing procedures. The disparity in care was greatest for those who had been psychiatric inpatients.

CONCLUSIONS

People with SMI, including both psychotic and affective disorders, receive less CRC care than the general population. This might contribute to higher case-fatality rates for an illness where the incidence is no higher than that of the general population. The reasons for this require further investigation, as does the extent to which differences in treatment access or quality contribute to excess CRC mortality in people with SMI.

The association between food insecurity and physical activity in adults with serious mental illness living in supportive housing

Rates of food insecurity are high among adults with serious mental illness (SMI); this population also engages in less physical activity than the general population. However, the relationship between food insecurity and physical activity in this group has not been explored. We examined food insecurity prevalence and its association with physical activity in 314 adults with SMI living in supportive housing in New York City and Philadelphia and enrolled in an institutional review board-approved randomized controlled trial of a Peer Group Lifestyle Balance (PGLB) program. We analyzed 2014 baseline survey data, including demographic data and self-reported food security, and four self-reported physical activity outcomes: any physical activity per week (yes/no) and 2) total, 3) moderate, or 4) vigorous physical activity minutes per week. A logistic regression model examined food security as a predictor of any physical activity; zero-inflated negative binomial regression models were used for the other three physical activity outcomes; demographic and clinical predictors were assessed for inclusion in models. Over half of participants (51.7%) reported low or very low levels of food security. Relationships between food insecurity and three physical activity measures (any physical activity, total weekly minutes, and moderate weekly minutes) were non-significant; those with lower food security were more likely to engage in vigorous physical activity. The high food insecurity prevalence highlights the importance of measuring and addressing food security in populations experiencing SMI; measuring physical activity is also important for tailored lifestyle recommendations. Future studies should examine longitudinal changes in food security and physical activity.

Epidemiology of trauma in patients with mental disorders

Objectives

We aimed to explore the influence of mental disorders on the risk of developing complications and in-hospital mortality after trauma.

Methods

We conducted an institutional review board-approved cohort study of 23 500 adult patients admitted to the Puerto Rico Trauma Hospital from 2002 to 2019. Participants were divided into 2 groups according to the presence or absence of psychiatric illnesses. Logistic regressions were employed to investigate the effect of mental illness on study outcomes.

Results

Psychiatric illness was associated with higher risk of complications; this risk increased with age. The pattern was accentuated for those with substance use disorders (SUD) and attenuated for those with non-substance-related diagnoses (NSRD). Psychiatric patients with Glasgow Coma Scale (GCS) scores of 15 had a 42% (95% CI 1.17 to 1.73) higher risk of dying, while the opposite was seen for those with scores <15 (adjusted OR=0.79; 95% CI 0.64 to 0.99). SUD was associated with a 51% (95% CI 1.21 to 1.88) higher risk of death in patients with GCS scores of 15, while NSRD was linked to a 49% (95% CI 0.33 to 0.79) lower odds of death among subjects with scores <15.

Conclusions

Our results suggest that trauma patients with SUD are at increased risk of developing complications and those with SUD and GCS scores of 15 are at increased risk of death. Mental health screening is an essential component of the management of trauma patients. Stratifying based on mental health disorders may be helpful during the clinical management of trauma patients, as those with SUD may benefit from more aggressive management.

Level of evidence

Level 4, prognostic and epidemiological study.

Study type

Original retrospective cohort study.

Thalamo-hippocampal dysconnectivity is associated with serum cholesterol level in drug-naïve patients with first-episode schizophrenia

Hippocampal deficits and metabolic dysregulations such as dyslipidemia have been frequently reported in schizophrenia and are suggested to contribute to the pathophysiology of schizophrenia. Hippocampus is particularly susceptible to environmental challenges including metabolism and inflammation. However, evidence linking hippocampal alterations and metabolic dysregulations are quite sparse in drug-naïve schizophrenia. A total of 166 drug-naïve patients with first-episode schizophrenia (FES) and 78 healthy controls (HC) underwent measures for several serum metabolic markers, structural and resting-state functional magnetic resonance imaging (rs-fMRI), as well as diffusion tensor imaging (DTI). Seed-to-voxel functional connectivity (FC) and probabilistic tractography were performed to assess the functional and microstructural connectivity of the bilateral hippocampi. Clinical symptoms were evaluated with Positive and Negative Syndrome Scale (PANSS). Patients with FES showed significantly decreased total cholesterol (Chol) level. Patients showed elevated FC between the left hippocampus and bilateral thalami while showing decreased microstructural connectivity between the left hippocampus and bilateral thalami. Multiple regression analyses showed that FC from the left hippocampus to the right superior frontal gyrus (SFG), bilateral frontal pole (FP), and right thalamus were negatively associated with the Chol level, while no association was observed in the HC group. Our study validated alterations in both functional and microstructural thalamo-hippocampal connectivities, and abnormal cholesterol level in FES. Moreover, decreased cholesterol level is associated with elevated thalamo-hippocampal functional connectivity in patients with FES, suggesting that dyslipidemia may interact with the hippocampal dysfunction in FES.

Treatment pearls: Management of physical healthcare needs in patients with mental illness

ABSTRACT

Clinicians caring for persons with mental illness should be aware of increased mortality, physical problems, and health disparities in this population. This article provides a brief overview of physical health problems in the context of mental illness as well as those related to psychotropic medications, and discusses strategies to manage treatment effectively.

Prevalence of type 2 diabetes in psychiatric disorders: an umbrella review with meta-analysis of 245 observational studies from 32 systematic reviews

AIMS/HYPOTHESIS

Estimates of the global prevalence of type 2 diabetes vary between 6% and 9%. The prevalence of type 2 diabetes has been investigated in psychiatric populations but a critical appraisal of the existing evidence is lacking, and an overview is needed. This umbrella review summarises existing systematic reviews of observational studies investigating the prevalence of type 2 diabetes in people with a psychiatric disorder.

METHODS

We searched PubMed, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews from inception to 17 January 2021 and screened reference lists of included systematic reviews. On the basis of prespecified criteria, we included systematic reviews investigating the prevalence of type 2 diabetes in adults (aged ≥18 years) with a psychiatric disorder. Titles and abstracts of 5155 identified records and full texts of 431 selected studies were screened by two independent reviewers, based on predefined eligibility criteria and an a priori developed extraction form, following the PRISMA and MOOSE guidelines. Risk of bias was assessed with the ROBIS instrument. Data extracted from primary studies were synthesised using random-effects meta-analyses.

RESULTS

A total of 32 systematic reviews with 245 unique primary studies were identified and met inclusion criteria. Twelve had low risk of bias. They reported type 2 diabetes prevalence estimates ranging from 5% to 22% depending on the specific psychiatric disorder. We meta-analysed data for ten categories of psychiatric disorders and found the following prevalence estimates of type 2 diabetes: in people with a sleep disorder: 40%; binge eating disorder: 21%; substance use disorder: 16%; anxiety disorder: 14%; bipolar disorder: 11%; psychosis: 11%; schizophrenia: 10%; a mixed group of psychiatric disorders: 10%; depression: 9%; and in people with an intellectual disability 8%. All meta-analyses revealed high levels of heterogeneity.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes is a common comorbidity in people with a psychiatric disorder. Future research should investigate whether routine screening for type 2 diabetes and subsequent prevention initiatives for these people are warranted. PROSPERO registration no. CRD42020159870.

Attitudes and Beliefs on Aging Among Middle-Aged and Older Adults With Serious Mental Illness

Older adults with serious mental illness (SMI) experience increased medical comorbidities, disability, and early mortality, but little is known about how they perceive the process of aging. This study explored attitudes and beliefs about aging among n = 20 middle aged and older adults (M = 59.8 years; range 47-66) with SMI in a state psychiatric hospital. We conducted semistructured interviews using the Attitudes to Ageing Questionnaire (AAQ) and analyzed narrative accounts using a grounded theory approach. The mean scores of overall attitudes toward aging and of the subscale of perception of psychological growth were both positive compared to a neutral rating (p = 0.026 and p = 0.004, respectively). Study participants rated their experience on the subscales of psychosocial loss and physical health change as neutral. Despite substantial psychiatric, medical, and functional disabilities, older adults with SMI in this study of psychiatric inpatients perceived the process of aging as generally positive, suggesting resilience and potential positive emotional growth in older age.

The Health Improvement Profile for people with severe mental illness: Feasibility of a secondary analysis to make international comparisons

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates. No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: It appears feasible to use the HIP to profile and compare physical health-related risks in people with SMI across different international settings. The HIP tool identified significant differences in areas of risk across the four countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The HIP could be used to identify unique clusters of health promotion needs in different countries. Use of HIP health checks may support implementation of individualized interventions. ABSTRACT: Introduction To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi-national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources.

Comorbidity combinations in schizophrenia inpatients and their associations with service utilization: A medical record-based analysis using association rule mining

BACKGROUND

Comorbidities are common among patients with schizophrenia yet the prevalence of comorbidity combinations and their associations with inpatient service utilization and readmission have been scarcely explored.

METHODS

Data were extracted from discharge summaries of patients whose primary diagnosis was schizophrenia spectrum disorders (ICD-10: F20-F29). We identified 30 most frequent comorbidities in patients' secondary diagnoses and then used the association rule mining (ARM) method to derive comorbidity combinations associated with length of stay (LOS), daily expense and one-year readmission.

RESULTS

The study included data from 8252 patients. The top five most common comorbidities were extrapyramidal syndrome (EPS, 44.58%), constipation (31.63%), common cold (21.80%), hyperlipidemia (20.99%) and tachycardia (19.13%). Most comorbidity combinations identified by ARM were significantly associated with longer LOS (≥70 days), few were associated with higher daily expenses, and fewer with readmission. The 3-way combination of common cold, hyperlipidemia and fatty liver had the strongest association with longer LOS (adjusted OR (aOR): 3.38, 95% CI: 2.12-5.38). The combination of EPS and mild cognitive disorder was associated with higher daily expense (≥700 RMB) (aOR: 1.67, 95% CI: 1.20-2.31). The combination of constipation, tachycardia and fatty liver were associated with higher 1-year readmission (aOR: 2.05, 95% CI: 1.03-4.09).

CONCLUSION

EPS, constipation, and tachycardia were among the most commonly reported comorbidities in schizophrenia patients in Beijing, China. Specific groups of comorbidities may contribute to higher inpatient psychiatric service utilization and readmission. The mechanism behind the associations and potential interventions to optimize service use warrant further investigation.

Disparities in COVID-19 infection, hospitalisation and death in people with schizophrenia, bipolar disorder, and major depressive disorder: a cohort study of the UK Biobank

People with severe mental illness (SMI; including schizophrenia/psychosis, bipolar disorder (BD), major depressive disorder (MDD)) experience large disparities in physical health. Emerging evidence suggests this group experiences higher risks of infection and death from COVID-19, although the full extent of these disparities are not yet established. We investigated COVID-19 related infection, hospitalisation and mortality among people with SMI in the UK Biobank (UKB) cohort study. Overall, 447,296 participants from UKB (schizophrenia/psychosis = 1925, BD = 1483 and MDD = 41,448, non-SMI = 402,440) were linked with healthcare and death records. Multivariable logistic regression analysis was used to examine differences in COVID-19 outcomes by diagnosis, controlling for sociodemographic factors and comorbidities. In unadjusted analyses, higher odds of COVID-19 mortality were seen among people with schizophrenia/psychosis (odds ratio [OR] 4.84, 95% confidence interval [CI] 3.00-7.34), BD (OR 3.76, 95% CI 2.00-6.35), and MDD (OR 1.99, 95% CI 1.69-2.33) compared to people with no SMI. Higher odds of infection and hospitalisation were also seen across all SMI groups, particularly among people with schizophrenia/psychosis (OR 1.61, 95% CI 1.32-1.96; OR 3.47, 95% CI 2.47-4.72) and BD (OR 1.48, 95% CI 1.16-1.85; OR 3.31, 95% CI 2.22-4.73). In fully adjusted models, mortality and hospitalisation odds remained significantly higher among all SMI groups, though infection odds remained significantly higher only for MDD. People with schizophrenia/psychosis, BD and MDD have higher risks of COVID-19 infection, hospitalisation and mortality. Only a proportion of these disparities were accounted for by pre-existing demographic characteristics or comorbidities. Vaccination and preventive measures should be prioritised in these particularly vulnerable groups.

Physical comorbidity and use of healthcare services in people with schizophrenia: protocol for a systematic review

INTRODUCTION

People with schizophrenia die about 15-20 years earlier than the general population. A constellation of factors contributes to this gap in life expectancy: side effects of psychotropic drugs, unhealthy lifestyles (inactivity, unhealthy diet) and inequality in the provision of healthcare services. This is a topic of main importance, which requires constant update and synthesis of the literature. The aim of this review is to explore the evidence of physical comorbidity and use of healthcare services in people with schizophrenia.

METHODS AND ANALYSIS

We will conduct a systematic literature search in the databases PubMed/MEDLINE, EMBASE, Scopus, Web of Science, PsycINFO and Cochrane Library, Proquest Health Research Premium Collection, in order to identify studies that answer to our research question: Are patients with schizophrenia different from the non-psychiatric population in terms of physical comorbidity and use of healthcare services? Two authors will independently review the studies and extract the data.

ETHICS AND DISSEMINATION

This study does not include human or animal subjects. Thus, ethics considerations are not applicable. Dissemination plans include publications in peer-reviewed journals and discussion of results in psychiatric congresses.

PROSPERO REGISTRATION NUMBER

CRD42020139972.

Effects of intranasal oxytocin in food intake and craving: A meta-analysis of clinical trials

OBJECTIVE

A rise of endogenous oxytocin (OT) is associated with anxiety and meal size reduction, and the effects of intranasal OT (INOT) have been examined in the management of food intake and craving. However, the discrepancy INOT effects in different disease populations are not entirely clear.

RESEARCH DESIGN AND METHODS

Updated systematic review and meta-analysis. By systematically searching the PubMed, Embase and Cochrane Library, we obtained 12 controlled trials. We performed meta-analyses to examine food intake, craving, anxiety or stress reduction on INOT administration, using standard mean difference (SMD) with a 95% confidence interval (CI) and a random-effects model.

RESULTS

This study examined 12 trials with 266 non-psychiatric and 157 psychiatric participants. The pooled results showed that single-dose INOT induced a significant lesser food intake in non-psychiatric subjects (SMD: -0.66 [95% CI: -1.18, -0.14]), but no effects was found in anorexia nervosa (AN) (SMD: 0.17 [95% CI: -0.32, 0.66]), bulimia nervosa (BN) and binge eating disorder (BED) (SMD: -0.41 [95% CI: -0.94, 0.11]), and schizophrenia (SMD: 0.04 [95% CI: -0.94, 1.02] subjects. Further analysis on leisure food also indicated an inhibition of consumption of chocolate biscuits in non-psychiatric subjects. Neither the non-psychiatric (SMD: -0.08 [95% CI: -0.50, 0.33]) nor the BN and BED (SMD: -0.08 [95% CI: -0.72, 0.88]) and schizophrenia subjects (SMD: -0.07 [95% CI: -1.05, 0.91]) demonstrated a difference in food craving or hunger compared with placebo. Anxiety or stress level was not influenced by INOT in any subgroup (non-psychiatric, SMD: 0.19 [95% CI: -0.22, 0.60]; AN, SMD: -0.01 [95% CI: -0.28, 0.88]; BN and BED: SMD: 0.00 [95% CI: -0.80, 0.80]).

CONCLUSIONS

Single-dose INOT significantly reduces food intake in nonpsychiatric subjects, and further studies are necessary to assess the long-term effects and safety in obese patients. Whether INOT could be a treatment option for patients with eating disorders remains to be investigated.

Ideal Cardiovascular Health in Racially and Ethnically Diverse People with Serious Mental Illness

Cardiovascular disease is a primary contributor to premature death among people with serious mental illness (SMI). This study used baseline data (N=314) from an effectiveness trial testing a healthy lifestyle intervention for racial/ethnically diverse participants with overweight/obesity and SMI living in supportive housing. We examined the prevalence and correlates of a modified version of the American Heart Association (AHA) metric of ideal cardiovascular health (ICVH). Five AHA ICVH metrics (smoking, body mass index, diet, physical activity, and blood pressure) were used to create a composite ICVH score. The mean ICVH score was 3.15 (range 0-8). Multivariate analysis indicated that higher ICVH scores were associated with lifetime cancer diagnosis and better cardiorespiratory fitness. Lower scores were associated with female gender, racial/ethnic minority status, and antipsychotic use, suggesting that these subgroups of people with SMI may benefit from targeted screening and interventions to improve their cardiovascular health.

Elucidating the relationship between white matter structure, demographic, and clinical variables in schizophrenia-a multicenter harmonized diffusion tensor imaging study

White matter (WM) abnormalities are repeatedly demonstrated across the schizophrenia time-course. However, our understanding of how demographic and clinical variables interact, influence, or are dependent on WM pathologies is limited. The most well-known barriers to progress are heterogeneous findings due to small sample sizes and the confounding influence of age on WM. The present study leverages access to the harmonized diffusion magnetic-resonance-imaging data and standardized clinical data from 13 international sites (597 schizophrenia patients (SCZ)). Fractional anisotropy (FA) values for all major WM structures in patients were predicted based on FA models estimated from a healthy population (n = 492). We utilized the deviations between predicted and real FA values to answer three essential questions. (1) "Which clinical variables explain WM abnormalities?". (2) "Does the degree of WM abnormalities predict symptom severity?". (3) "Does sex influence any of those relationships?". Regression and mediator analyses revealed that a longer duration-of-illness is associated with more severe WM abnormalities in several tracts. In addition, they demonstrated that a higher antipsychotic medication dose is related to more severe corpus callosum abnormalities. A structural equation model revealed that patients with more WM abnormalities display higher symptom severity. Last, the results exhibited sex-specificity. Males showed a stronger association between duration-of-illness and WM abnormalities. Females presented a stronger association between WM abnormalities and symptom severity, with IQ impacting this relationship. Our findings provide clear evidence for the interaction of demographic, clinical, and behavioral variables with WM pathology in SCZ. Our results also point to the need for longitudinal studies, directly investigating the casualty and sex-specificity of these relationships, as well as the impact of cognitive resiliency on structure-function relationships.

Screening and Treatment of Tobacco Use Disorder in Mental Health Clinics in New York State: Current Status and Potential Next Steps

The prevalence of smoking is higher among individuals with serious mental illnesses than the general population. Evidence-based practices exist for tobacco cessation, but little is known about mental health clinics' tobacco cessation treatment practices/protocols. Mental health clinics in New York State were surveyed about their tobacco use treatment protocols and outdoor-smoking policies. One-third of clinics were not providing individual counseling for tobacco use disorder, 39% were not prescribing nicotine replacement therapy, and nearly half reported not prescribing bupropion or varenicline. Even smaller proportions reported implementing other clinical practice guidelines, with only 25.2% providing staff training and 20.3% having a dedicated staff member for coordinating tobacco use disorder treatment. Regarding outdoor smoke-free policies, 38% of clinics reported not allowing any tobacco use anywhere on grounds. Despite some successes, many clinics do not provide evidence-based tobacco use treatments, meaning important opportunities exist for mental health clinics and oversight agencies to standardize practices.

An Educational Intervention for Mental Health Staff to Assess Clients' Diabetic Self-Care Skills for Self-Management and Safe Transition into the Community

The current project's objective was to increase mental health assessor's knowledge about type 2 diabetes after attending a nurse practitioner's presentation. Mental health assessors, primarily social workers, help transition individuals with severe mental illness (SMI) and comorbidities from inpatient nursing homes back into the community. The assessor's knowledge about individual comorbidities, such as diabetes, is crucial for a successful long-term community transition. Mental health assessors were given the Diabetes Knowledge Test 2 pre- and post-educational intervention. The post-test intervention revealed assessors' knowledge increased by 25% in knowledge about diabetes and 225% in ability to use a glucometer. Mental health assessors also maintained their increased knowledge 3 months post-intervention. Emboldened with this knowledge, mental health assessors are better prepared to facilitate safe transfer of individuals with diabetes and SMI back into the community. Mental health assessors may also help prevent unnecessary emergency department visits and/or hospitalizations. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Community socioeconomic disadvantage drives type of 30-day medical-surgical revisits among patients with serious mental illness

Background

Patients with serious mental illness (SMI) are vulnerable to medical-surgical readmissions and emergency department visits.

Methods

We studied 1,914,619 patients with SMI discharged after medical-surgical admissions in Florida and New York between 2012 and 2015 and their revisits to the hospital within 30 days of discharge.

Results

Patients with SMI from the most disadvantaged communities had greater adjusted 30-day revisit rates than patients from less disadvantaged communities. Among those that experienced a revisit, patients from the most disadvantaged communities had 7.3 % greater 30-day observation stay revisits.

Conclusions

These results suggest that additional investments are needed to ensure that patients with SMI from the most disadvantaged communities are receiving appropriate post-discharge care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06605-y.

Hospital Nurse Competency to Care for Patients With Behavioral Health Concerns: A Follow-Up Study

Nonpsychiatric nurses care for hospital patients with behavioral health (BH) conditions. This study found BH care competencies of hospital nurses slightly changed from those 9 years earlier. On average, nurses reported moderate to strong perceived competence about assessing/intervening and accessing resources to care for BH patients. They perceived less competence in recommending psychotropic drugs for patients who may need them. Staff development programs that aim to enhance nurse BH care competencies are needed.

[Disease burden of borderline personality disorder: cost of illness, somatic comorbidity and mortality]

BACKGROUND

Severe mental illnesses (SMI) are characterized by high psychosocial impairment as well as by increased somatic morbidity and mortality. The term SMI commonly includes psychotic, bipolar and severe unipolar depressive disorders but borderline personality disorder (BPD) also shows severe sequelae of the disease.

MATERIAL AND METHODS

Published reviews and studies since 2010 examining disease burden of BPD, in terms of direct and indirect costs of illness, somatic comorbidity, and mortality were included. Furthermore, administrative data (clinically recorded billing data in Germany), comorbidity and mortality from a comprehensive analysis (n > 59 million, age ≥ 18 years) are reported.

RESULTS

International studies reveal an increased disease burden, comorbidity, and mortality for BPD. In Germany BPD (administrative 1‑year prevalence 0.34%) is associated with increased rates of somatic sequelae of trauma, hepatitis, HIV, COPD, asthma, and obesity. The estimated reduced life expectancy is 5.0-9.3 years of life lost (depending on age and sex).

DISCUSSION

The burden of disease in BPD is clearly increased (cost of illness, somatic comorbidity and mortality). The increased mortality can mainly be explained by deaths as a consequence of poor physical health and associated BPD-related health behavior and only to a lesser degree by suicide. These results highlight the importance of classifying BPD as an SMI and the necessity to provide not only psychotherapeutic and psychiatric but also adequate somatic prevention and treatment. Individual improvement of everyday care as well as establishing new interdisciplinary and multiprofessional services could enhance health equality for people with BPD.

The prevalence and independent influencing factors of obesity and underweight in patients with schizophrenia: a multicentre cross-sectional study

BACKGROUND

Few studies have investigated the weight of patients with schizophrenia in China.

OBJECTIVE

The aim of this study was to analyse the prevalence, clinical characteristics and influencing factors of obesity and underweight in patients with chronic schizophrenia in China.

METHODS

A total of 325 patients with schizophrenia and 172 sex- and age-matched healthy controls from the community were recruited. Socio-demographic data and laboratory measurements were collected for all subjects. Using the Positive and Negative Syndrome Scale (PANSS), we evaluated the psychiatric symptoms of patients with schizophrenia. According to the body mass index (BMI) criteria in China, BMI ≥ 28 kg/m² indicates obesity, and BMI < 18.5 kg/m² indicates underweight.

RESULTS

Of the patients with schizophrenia, 16.3% were obese, and 6.8% were underweight; 11.0% of the healthy controls were obese, and 3.5% were underweight. There was no difference between the two groups in the prevalence of obesity and underweight. After controlling for relevant variables, the obesity rate remained non significant, but the underweight rate appeared to be different. The multinomial regression analysis revealed that among the patients with schizophrenia, female sex, triglyceride level and LDL level were independent risk factors for obesity and that HDL level was an independent protective factor against obesity. In contrast, male sex and HDL level were independent risk factors for underweight.

CONCLUSION

We found that the patients with schizophrenia had an increased rate of underweight and some factors related to weight.

LEVEL OF EVIDENCE

Level V, descriptive study.

Mental illness as a predictor of patient attendance and anthropometric changes: observations from an Australian publicly funded obesity management service

OBJECTIVE

Obesity is associated with co-morbid mental illness. The Canberra Obesity Management Service (OMS) supports adults with severe obesity who have the psychosocial capacity to engage. This study will determine whether mental illness is a predictor of OMS attendance and anthropometric changes.

METHOD

A retrospective audit was performed from July 2016 to June 2017. Baseline characteristics, attendance and anthropometrics were stratified according to the presence of mental illness. Outcomes included weight stabilisation and clinically significant weight loss. Descriptive analyses were performed.

RESULTS

Mental illness was present in 60/162 patients (37%). Attendance was similar for those with and without mental illness. Patients with mental illness had twice as many co-morbidities (p = .001). Depressive disorders were most common (n = 28, 47%). Anxiety, schizophrenia spectrum and other psychotic disorders, and trauma- and stressor-related disorders also featured. Weight stabilisation was achieved by 25 patients (66%) with mental illness and 25 (35%) without. Clinically significant weight loss was observed in 10 patients (26%) with and 26 (40%) without mental illness.

CONCLUSION

The presence of mental illness did not impact OMS attendance or weight stabilisation. The higher rate of co-morbidities in those with mental illness highlights the challenges faced by this vulnerable population.

Discovery of Association Rules Patterns and Prevalence of Comorbidities in Adult Patients Hospitalized with Mental and Behavioral Disorders

The objectives of this study were to identify the prevalence of comorbidities of mental and behavioral disorders and to identify the association rules related to comorbidities as a way to improve patient management efficiently. We extracted comorbidities of 20,690 patients (≥19 years old) whose principal diagnosis was a mental disorder from the Korean National Hospital Discharge In-depth Injury Survey (KNHDS) between 2006 and 2016. Association rules analysis between comorbid diseases using the Apriori algorithm was used. The prevalence of comorbidities in all patients was 61.98%. The frequent comorbidities of mental and behavioral disorders were analyzed in the order of hypertensive diseases (11.06%), mood disorders (8.34%), diabetes mellitus (7.98%), and diseases of esophagus, stomach, and duodenum (7.04%). Nine major association pathways were analyzed. Significant pathways were analyzed as diabetes mellitus and hypertensive diseases (IS scale = 0.386), hypertensive diseases, and cerebrovascular diseases (IS scale = 0.240). The association pathway of diabetes mellitus and hypertensive diseases was common in subgroups of mental and behavioral disorders, excluding mood disorders and disorders of adult personality and behavior. By monitoring related diseases based on major patterns, it can predict comorbid diseases in advance, improve the efficiency of managing patients with mental and behavioral disorders, and furthermore, it can be used to establish related health policies.

Treatment of Patients with Mental Illness Amid A Global COVID-19 Pandemic

A newly discovered coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing pandemic of coronavirus disease 2019 (COVID-19), which is not only physically challenging but also has many subtle and overt mental impacts. The concern of being infected, lack of antiviral agents, preventive strategies of social distancing, and home isolation have created unrest in the society. The way of reacting to emergencies varies from individual to individual, and that this variability lies in our unique personality traits. The COVID-19 pandemic is testing the mental stability of all of us, and hence it is crucial to recognize the vulnerable population and support them to prevent or minimize the catastrophe like post-traumatic stress disorder (PTSD), emotional trauma, and suicides. In this context, the role of psychiatrists, psychotherapists, and other mental healthcare providers is indispensable.

Adapting the Comprehensive Unit Safety Program (CUSP) implementation strategy to increase delivery of evidence-based cardiovascular risk factor care in community mental health organizations: protocol for a pilot study

BACKGROUND

People with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder experience excess mortality driven in large part by high rates of poorly controlled and under-treated cardiovascular risk factors. In the USA, integrated "behavioral health home" models in which specialty mental health organizations coordinate and manage physical health care for people with SMI are designed to improve guideline-concordant cardiovascular care for this group. Such models have been shown to improve cardiovascular care for clients with SMI in randomized clinical trials, but real-world implementation has fallen short. Key implementation barriers include lack of alignment of specialty mental health program culture and physical health care coordination and management for clients with SMI and lack of structured protocols for conducting effective physical health care coordination and management in the specialty mental health program context. This protocol describes a pilot study of an implementation intervention designed to overcome these barriers.

METHODS

This pilot study uses a single-group, pre/post-study design to examine the effects of an adapted Comprehensive Unit Safety Program (CUSP) implementation strategy designed to support behavioral health home programs in conducting effective cardiovascular care coordination and management for clients with SMI. The CUSP strategy, which was originally designed to improve inpatient safety, includes provider training, expert facilitation, and implementation of a five-step quality improvement process. We will examine the acceptability, appropriateness, and feasibility of the implementation strategy and how this strategy influences mental health organization culture; specialty mental health providers' self-efficacy to conduct evidence-based cardiovascular care coordination and management; and receipt of guideline-concordant care for hypertension, dyslipidemia, and diabetes mellitus among people with SMI.

DISCUSSION

While we apply CUSP to the implementation of evidence-based hypertension, dyslipidemia, and diabetes care, this implementation strategy could be used in the future to support the delivery of other types of evidence-based care, such as smoking cessation treatment, in behavioral health home programs. CUSP is designed to be fully integrated into organizations, sustained indefinitely, and used to continually improve evidence-based practice delivery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04696653 . Registered on January 6, 2021.

Barriers to Somatic Health Care for Persons With Severe Mental Illness in Belgium: A Qualitative Study of Patients' and Healthcare Professionals' Perspectives

BACKGROUND

A huge and still growing mortality gap between people with severe mental illness (SMI) and the general population exists. Physical illnesses, mainly cardiovascular diseases, substantially contribute to the high mortality rates in patients with SMI. Disparities in somatic health care access, utilisation, and provision contribute to these poor physical health outcomes.

METHODS

A qualitative study, using semi-structured interviews, was set up to explore SMI patients' and healthcare professionals' perspectives on somatic health care in different psychiatric settings of the three Belgian regions (Flanders, Brussels, Wallonia). Interviews were digitally recorded and transcribed prior to qualitative inductive thematic analysis, using Nvivo software. The COnsolidated criteria for REporting Qualitative research (COREQ) were used for reporting methods and findings.

RESULTS

Collaboration and information flows between psychiatric healthcare professionals, non-psychiatric healthcare professionals, and persons with SMI were troublesome. This seemed to be mainly due to stigma and prejudice and challenging communication and data transfer. Lack of sufficient training and experience to identify and treat somatic health problems in people with SMI (for psychiatrists and psychiatric nurses) and lack of psychiatric knowledge and feeling or sensitivity for psychiatric patients (for non-psychiatric healthcare professionals) further complicated adequate somatic health care. Finally, optimal somatic follow-up of patients with SMI was hampered by organisational problems (unavailability of equipment, unadapted infrastructure, understaffing, hospital pharmacy issues, and insufficient health promotion/lifestyle interventions), patient-related issues (unawareness of physical problems, non-adherence, need for accompaniment) and financial barriers.

CONCLUSION

There is an urgent need for integrated somatic and mental healthcare systems and a cultural change. Psychiatrists and primary care providers continue to consider the mental and physical health of their patients as mutually exclusive responsibilities due to a lack of sufficient training and experience, poor or absent liaison links, time constraints and organisational and financial barriers. Modifying these aspects will improve the quality of somatic health care for these vulnerable patients.

Implementing COVID-19 Mitigation in the Community Mental Health Setting: March 2020 and Lessons Learned

In March 2020, at the beginning of the COVID-19 pandemic, state-funded community mental health service programs (CMHSP) in Michigan, organized into 10 regions known as a "Prepaid Inpatient Health Plan" (PIHP), grappled with the task of developing a modified plan of operations, while complying with mitigation and social distancing guidelines. With the premise that psychiatric care is essential healthcare, a panel of physician and non-physician leaders representing Region 5, met and developed recommendations, and feedback iteratively, using an adaptive modified Delphi methodology. This facilitated the development of a service and patient prioritization document to triage and to deliver behavioral health services in 21 counties which comprised Region 5 PIHP. Our procedures were organized around the principles of mitigation and contingency management, like physical health service delivery paradigms. The purpose of this manuscript is to share region 5 PIHP's response; a process which has allowed continuity of care during these unprecedented times.

Diabesity and Perinatal Mental Health: Evidence-based Recommendations for Screening and Intervention

Perinatal mental illness, obesity, and diabetes mellitus are common complications of the perinatal period that are becoming ever more prevalent and frequently co-occur. This review seeks to examine the prevalence of comorbid obesity/diabetes (termed "diabesity") and mental illness in the perinatal period and current understandings of the psychosocial and pathophysiological relationships between these diseases. We will present current guidelines for screening and make recommendations for adaptations of mental health treatment in patients with this comorbidity. Finally, we present future directions for research and clinical intervention.

Integrating Mental Health and Addiction Treatment Into General Medical Care: The Role of Policy

Interventions that integrate care for mental illness or substance use disorders into general medical care settings have been shown to improve patient outcomes in clinical trials, but efficacious models are complex and difficult to scale up in real-world practice settings. Existing payment policies have proven inadequate to facilitate adoption of effective integrated care models. This article provides an overview of evidence-based models of integrated care, discusses the key elements of such models, considers how existing policies have fallen short, and outlines future policy strategies. Priorities include payment policies that adequately support structural elements of integrated care and incentivize multidisciplinary team formation and accountability for patient outcomes, as well as policies to expand the specialty mental health and addiction treatment workforce and address the social determinants of health that disproportionately influence health and well-being among people with mental illness or substance use disorders.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

COVID-19 Emergency Reforms in Massachusetts to Support Behavioral Health Care and Reduce Mortality of People With Serious Mental Illness

People with serious mental illness are at disproportionate risk of COVID-19 morbidity and mortality because of high rates of risk factors that directly parallel those related to poor coronavirus outcomes, including smoking, chronic obstructive pulmonary disease, cardiovascular disease, and diabetes, along with housing instability, homelessness, food insecurity, and poverty. Community-based behavioral health organizations are also at risk of adverse outcomes because of dramatic declines in revenues and a diminished workforce. The State of Massachusetts has responded to this crisis by rapidly implementing a variety of policy, regulatory, and payment reforms. This column describes some of these reforms, which are designed to enhance remote telehealth delivery of care, ensure access to needed medications and residential care staff, and support the financial livelihood of community-based behavioral health services.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).