Energy expenditure and physical activity in clozapine use: implications for weight management

Neuroreceptor Inhibition by Clozapine Triggers Mitohormesis and Metabolic Reprogramming in Human Blood Cells

The antipsychotic drug clozapine demonstrates superior efficacy in treatment-resistant schizophrenia, but its intracellular mode of action is not completely understood. Here, we analysed the effects of clozapine (2.5-20 µM) on metabolic fluxes, cell respiration, and intracellular ATP in human HL60 cells. Some results were confirmed in leukocytes of clozapine-treated patients. Neuroreceptor inhibition under clozapine reduced Akt activation with decreased glucose uptake, thereby inducing ER stress and the unfolded protein response (UPR). Metabolic profiling by liquid-chromatography/mass-spectrometry revealed downregulation of glycolysis and the pentose phosphate pathway, thereby saving glucose to keep the electron transport chain working. Mitochondrial respiration was dampened by upregulation of the F0F1-ATPase inhibitory factor 1 (IF1) leading to 30-40% lower oxygen consumption in HL60 cells. Blocking IF1 expression by cotreatment with epigallocatechin-3-gallate (EGCG) increased apoptosis of HL60 cells. Upregulation of the mitochondrial citrate carrier shifted excess citrate to the cytosol for use in lipogenesis and for storage as triacylglycerol in lipid droplets (LDs). Accordingly, clozapine-treated HL60 cells and leukocytes from clozapine-treated patients contain more LDs than untreated cells. Since mitochondrial disturbances are described in the pathophysiology of schizophrenia, clozapine-induced mitohormesis is an excellent way to escape energy deficits and improve cell survival.

Indirect Calorimetry to Measure Metabolic Rate and Energy Expenditure in Psychiatric Populations: A Systematic Review

Psychiatric and metabolic disorders are highly comorbid and the relationship between these disorders is bidirectional. The mechanisms underlying the association between psychiatric and metabolic disorders are presently unclear, which warrants investigation into the dynamics of the interplay between metabolism, substrate utilization, and energy expenditure in psychiatric populations, and how these constructs compare to those in healthy controls. Indirect calorimetry (IC) methods are a reliable, minimally invasive means for assessing metabolic rate and substrate utilization in humans. This review synthesizes the extant literature on the use of IC on resting metabolism in psychiatric populations to investigate the interaction between psychiatric and metabolic functioning. Consistently, resting energy expenditures and/or substrate utilization values were significantly different between psychiatric and healthy populations in the studies contained in this review. Furthermore, resting energy expenditure values were systematically overestimated when derived from predictive equations, compared to when measured by IC, in psychiatric populations. High heterogeneity between study populations (e.g., differing diagnoses and drug regimens) and methodologies (e.g., differing posture, time of day, and fasting status at measurement) impeded the synthesis of results. Standardized IC protocols would benefit this line of research by enabling meta-analyses, revealing trends within and between different psychiatric disorders.

Disordered Eating among People with Schizophrenia Spectrum Disorders: A Systematic Review

Disordered eating, or abnormal eating behaviours that do not meet the criteria for an independent eating disorder, have been reported among people with schizophrenia. We aimed to systemati-cally review literature on disordered eating among people with schizophrenia spectrum disorder (SSD). Seven databases were systematically searched for studies that described the prevalence and correlates of disordered eating among patients with SSD from January 1984 to 15 February 2021. Qualitative analysis was performed using the National Institutes of Health scales. Of 5504 records identified, 31 studies involving 471,159 subjects were included in the systematic review. The ma-jority of studies (17) rated fair on qualitative analysis and included more men, and participants in their 30s and 40s, on antipsychotics. The commonest limitations include lack of sample size or power calculations, poor sample description, not using valid tools, or not adjusting for con-founders. The reported rates were 4.4% to 45% for binge eating, 16.1% to 64%, for food craving, 27% to 60.6% for food addiction, and 4% to 30% for night eating. Positive associations were re-ported for binge eating with antipsychotic use and female gender, between food craving and weight gain, between food addiction and increased dietary intake, and between disordered eating and female gender, mood and psychotic symptoms. Reported rates for disordered eating among people with SSD are higher than those in the general population. We will discuss the clinical, treatment and research implications of our findings.

Effect of Bifidobacterium on olanzapine-induced body weight and appetite changes in patients with psychosis

RATIONALE

Gut microbiota plays an important role in host metabolism. Antipsychotic drugs can result in metabolic abnormalities. Probiotics may ameliorate the antipsychotic drug-induced metabolic abnormalities by regulating gut microbiota.

OBJECTIVE

To determine whether Bifidobacterium intervention can ameliorate olanzapine-induced weight increase.

METHODS

Enrolled patients were assigned to either the olanzapine or olanzapine plus Bifidobacterium group. The following were assessed: body weight, body mass index (BMI), appetite, latency to increased appetite, and baseline weight increase of more than 7%. All assessments were conducted at baseline and at 4, 8, and 12 weeks of treatment.

RESULTS

We enrolled 70 patients with schizophrenia or schizophrenic affective disorder, and 67 completed the study. Treatment for 4 weeks led to between-group differences in weight change (2.4 vs. 1.1 kg, p < 0.05) and BMI (0.9 vs. 0.4, p < 0.05). However, this difference disappeared at 8 and 12 weeks of treatment (both p > 0.05). The two groups did not differ in appetite increase at any time point (p > 0.05). The mean time from olanzapine initiation to appetite increase was also not significantly different between the two groups (t = 1.243, p = 0.220).

CONCLUSIONS

Probiotics may mitigate olanzapine-induced weight gain in the early stage of treatment and delay olanzapine-induced appetite increase.

Biopsychosocial factors associated with disordered eating behaviors in schizophrenia

BACKGROUND

Recent hypotheses have suggested that schizophrenic patients are more likely to consume unhealthy foods, causing increased rates of mortality and morbidity associated with metabolic syndrome. This raises the need for more in-depth research on disordered eating behaviors (DEBs) in schizophrenic patients. This study, therefore, aimed to investigate biopsychosocial factors associated with DEBs in schizophrenia.

METHODS

In this cross-sectional study, a total of 308 participants (including 83 subjects in the active phase of schizophrenia, 71 subjects in the remission phase of schizophrenia, and 154 control subjects) were recruited through convenience sampling among patients who referred to the Baharan Psychiatric hospital in Zahedan, Iran. Patients were assessed through Eating Attitudes Test (EAT-26), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), and Positive and Negative Syndrome Scale (PANSS). Data were analyzed using SPSS v25 software. Further, the statistical significance level was set at p < 0.05.

RESULTS

The prevalence of DEBs was 41.5% in schizophrenic patients (vs. 10.3% in the control group, p = 0.012). No significant difference was observed in the EAT-26 scores based on gender and phases of schizophrenia. According to multiple linear regression analysis, lack of psychosocial rehabilitation, use of atypical antipsychotics, early stages of psychosis, high level of anxiety and depression, expression of more active psychotic symptoms, tobacco smoking, and suffering from type 2 diabetes were all associated with increased development of DEBs among schizophrenic patients.

CONCLUSIONS

Since the occurrence of DEBs is independent of different phases of schizophrenia, the risk of DEBs is required to be evaluated during the entire course of schizophrenia especially at earlier stages of schizophrenia. Moreover, the use of psychosocial interventions, treatment of affective disorders (i.e., anxiety and depression), antipsychotic medication switching, treatment of tobacco smoking and type 2 diabetes may reduce the risk of DEBs among schizophrenic patients. However, further investigations are required to prove the actual roles of the above factors in developing DEBs among schizophrenic patients.

Susceptibility of male wild type mouse strains to antipsychotic-induced weight gain

While both men and women gain weight as a side effect of antipsychotic (AP) treatment, studies in mice have found only female mice are susceptible to weight gain. Therefore, to we set out to identify a strain of male mice that gain significant weight in response to APs which could better model AP-induced weight gain observed in humans. These studies determined that male Balb/c mice developed late onset olanzapine-induced weight gain. Patients often take APs for many years and thus understanding AP-mediated changes in food intake, energy expenditure and body weight regulation is particularly important.

Low Physical Activity and Cardiorespiratory Fitness in People With Schizophrenia: A Comparison With Matched Healthy Controls and Associations With Mental and Physical Health

Introduction: The aim of this study was to objectively assess time spent in physical activity (PA) and sedentary behavior (SB) in patients with schizophrenia compared to healthy controls matched for age, gender and socioeconomic status. Associations between both PA and cardiorespiratory fitness (CRF) and mental and physical health parameters in patients with schizophrenia were examined. Materials and Methods: Moderate and vigorous PA (MVPA), moderate PA, vigorous PA, total and active energy expenditure (TEE and AEE), number of steps, lying down and sleeping time was assessed with SenseWear Pro-2 body monitoring system for three 24-h bouts in patients with schizophrenia (n = 63) and matched healthy controls (n = 55). Severity of symptoms (Positive and Negative Syndrome Scale and Montgomery and Åsberg Depression Rating Scale), CRF (peak oxygen uptake, VO_2peak), body mass index (BMI), and metabolic syndrome were assessed. Results: Patients with schizophrenia performed less MVPA and moderate activity had lower TEE and AEE, spent more time per day lying down and sleeping, and had poorer CRF compared to healthy controls. The amount of MVPA, but especially CRF was associated with severity of negative symptoms in patients with schizophrenia. Only CRF was associated with BMI. Discussion: The current data offer further evidence for interventions aiming to increase physical activity and decrease sedentary behavior. Given strong associations of CRF with both negative symptoms and BMI, treatment aimed at CRF-improvement may prove to be effective.

Risk of diabetes and dyslipidemia during clozapine and other antipsychotic drug treatment of schizophrenia in Iceland

BACKGROUND

Type 2 diabetes (T2D) and raised blood lipids are associated with the use of antipsychotics, not least clozapine.

AIMS

To describe the prevalence of high blood glucose levels, T2D, and dyslipidemia, in association with the use of clozapine or other antipsychotics in patients with schizophrenia in Iceland.

METHOD

This study identified 188 patients treated with clozapine and 395 patients never treated with clozapine by searching the electronic health records of Landspitali, the National University Hospital. The comparison group consisted of Icelandic population controls. Data were obtained on blood glucose, HbA1c, and blood lipid levels from these health records.

RESULTS

The prevalence of T2D was 14.3% in the clozapine group, where the mean age was 51.2 years, and 13.7% in the never-on-clozapine group, where the mean age was 58.6 years. Males on clozapine were 2.3-times more likely and females 4.4-times more likely to have developed T2D than controls from an age-adjusted Icelandic cohort, while males on other antipsychotics were 1.5-times more likely and females 2.3-times as likely to have T2D than controls. Only one case of ketoacidosis was identified. Triglyceride levels were significantly higher in both treatment groups compared to controls in the age-adjusted Icelandic cohort.

CONCLUSIONS

Clinicians must take active steps to reduce the risk of T2D and raised triglycerides in patients with schizophrenia. Antipsychotics were associated with a greater risk of T2D developing in females compared to males.

Intrinsic and Antipsychotic Drug-Induced Metabolic Dysfunction in Schizophrenia

For decades, there have been observations demonstrating significant metabolic disturbances in people with schizophrenia including clinically relevant weight gain, hypertension, and disturbances in glucose and lipid homeostasis. Many of these findings pre-date the use of antipsychotic drugs (APDs) which on their own are also strongly associated with metabolic side effects. The combination of APD-induced metabolic changes and common adverse environmental factors associated with schizophrenia have made it difficult to determine the specific contributions of each to the overall metabolic picture. Data from drug-naïve patients, both from the pre-APD era and more recently, suggest that there may be an intrinsic metabolic risk associated with schizophrenia. Nevertheless, these findings remain controversial due to significant clinical variability in both psychiatric and metabolic symptoms throughout patients' disease courses. Here, we provide an extensive review of classic and more recent literature describing the metabolic phenotype associated with schizophrenia. We also suggest potential mechanistic links between signaling pathways associated with schizophrenia and metabolic dysfunction. We propose that, beyond its symptomatology in the central nervous system, schizophrenia is also characterized by pathophysiology in other organ systems directly related to metabolic control.

Prevention of the adverse effects of olanzapine on lipid metabolism with the antiepileptic zonisamide

BACKGROUND

Atypical antipsychotic drugs, particularly olanzapine, represent a mainstay in the treatment of psychoses; however, their use is commonly associated with weight gain and diabetes. The aim of this study was to determine whether combined administration of olanzapine and zonisamide can be used to prevent olanzapine-induced metabolic disturbances.

METHODS AND RESULTS

These experiments involved female Sprague Dawley rats (n = 6-8/group) that were administered olanzapine, either acutely (6 mg/kg, s. c) or via continuous osmotic minipump infusion (6 mg/kg/day for 6 or 14 days), in combination with zonisamide (26 mg/kg/day,i.p.). Continuous infusion of olanzapine induced accumulation of adipose tissue and an associated reduction in stimulated lipolysis and reduced protein expression of CGI-58, a critical co-activator of ATGL. Olanzapine treatment caused a preferential shift toward carbohydrate oxidation (or reduced fat oxidation), elevated blood triglycerides and a reduction in locomotor activity. Olanzapine had a direct effect on glucose regulation, causing rapid hyperglycemia, and a reduction in glucose tolerance and insulin sensitivity. Continuous administration of olanzapine caused significant hyperinsulinemia and a significant reduction in insulin sensitivity. Zonisamide did not affect the impact of olanzapine on glucose homeostasis. On the other hand, co-administration of olanzapine with zonisamide completely ameliorated olanzapine-mediated shifts in lipid metabolism resulting in a normalization of olanzapine-induced weight gain.

CONCLUSION

These data collectively show an impact of olanzapine on body weight and lipid metabolism, which is ameliorated by co-administration with zonisamide. These findings suggest that a combined olanzapine and zonisamide approach might reduce weight gain, but will not provide protection against olanzapine-induced glucose intolerance.

Risk of New-Onset Diabetes After Long-Term Treatment With Clozapine in Comparison to Other Antipsychotics in Patients With Schizophrenia

It has been suggested that clozapine has one of the largest diabetic effects of all atypical antipsychotics. To confirm these findings, we examined retrospectively the risk of new-onset diabetes in long-term clozapine treatment compared to treatment with other antipsychotics in a matched control population with schizophrenia or schizoaffective disorder. Ninety-four adult patients with schizophrenia or schizoaffective disorder who had been treated with clozapine for 5 years or longer were matched on age, diagnosis, and sex to 94 patients without any use of clozapine. The groups were followed up for as long as 20 years. The cumulative incidence of new detection of diabetes in the clozapine group was 22.3% (mean follow-up, 12.3 years; absolute risk difference, 6.3%; 95% confidence interval, -4.9% to 17.5%). An additional rigorous analysis of the 83 matched pairs with normal glucose measurement before end point showed a significant risk difference between the 2 groups (21.7% compared with 8.4%) but may have been biased against clozapine. We conclude that definitive evidence showing a clinically significant larger risk for new-onset diabetes after long-term treatment with clozapine in comparison to other antipsychotics is lacking.

Running for your life: A review of physical activity and cardiovascular disease risk reduction in individuals with schizophrenia

Individuals with schizophrenia have a greater risk for cardiometabolic risk factors (e.g. central obesity, insulin resistance, hypertension and dyslipidaemia), cardiovascular diseases and mortality. This risky profile may be explained by the adverse effects of antipsychotic medications and an unhealthy lifestyle (e.g. smoking, poor nutrition and low physical activity). In the general population, physical activity has been shown to be the optimal strategy to improve both cardiometabolic parameters and cardiorespiratory fitness levels. Accordingly, an emerging literature of non-pharmacological interventions (e.g. cognitive behavioural therapy, diet and physical activity) has been studied in individuals with schizophrenia. Therefore, the purpose of this review was 1) to conduct a critical literature review of non-pharmacological interventions that included some kind of physical activity (including supervised and unsupervised exercise training) and target cardiometabolic risk factors in individuals with schizophrenia. 2) To describe the contribution of physical activity alone by reviewing trials of supervised exercise training programmes only. A literature review via systematic keyword search for publications in Medline, PubMed, Embase and PsycINFO was performed. Many non-pharmacological interventions are efficient in reducing cardiovascular disease risk factors when combined with physical activity. Supervised physical activity has been successful in decreasing cardiovascular disease risk, and aerobic interval training appears to provide more benefits by specifically targeting cardiorespiratory fitness levels. In conclusion, physical activity is an effective strategy for addressing cardiovascular disease risk in individuals with schizophrenia. Long-term studies are needed to evaluate the feasibility and impact of exercise training programmes in individuals with schizophrenia.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Treatment of clozapine-associated weight gain: a systematic review

PURPOSE

Clozapine is an antipsychotic drug with superior efficacy in treatment-resistant schizophrenia. Clozapine is associated with a low likelihood of extrapyramidal symptoms and other neurological side-effects but a high propensity to induce weight gain and general metabolic dysregulation. Various pharmacological and behavioral treatment approaches for reducing clozapine-associated weight gain exist in the literature; however, there are currently no clear clinical guidelines as to which method is preferred. The aim of the current review is to systematically summarize studies that have studied both pharmacological and non-pharmacological interventions to attenuate or reverse clozapine-associated weight gain.

METHODS

A systematic review of EMBASE and MEDLINE databases of all articles published prior to January 2014 was conducted. Seventeen studies were identified as meeting inclusion criteria and included in the review.

RESULTS

Aripiprazole, fluvoxamine, metformin, and topiramate appear to be beneficial; however, available data are limited to between one and three randomized controlled trials per intervention. Orlistat shows beneficial effects, but in males only. Behavioral and nutritional interventions also show modest effects on decreasing clozapine-associated weight gain, although only a small number of such studies exist.

CONCLUSIONS

While a number of pharmacological interventions can produce modest weight loss, each may be associated with negative side effects, which should be considered before beginning treatment. Given the pressing need to improve cardiometabolic health in most clozapine-treated patients, substantially more research is needed to develop sound clinical practice guidelines for the treatment of clozapine-associated weight gain.

Aerobic fitness and body mass index in individuals with schizophrenia: Implications for neurocognition and daily functioning

Previous reports indicate that among healthy individuals low aerobic fitness (AF) and high body-mass index (BMI) predict poor neurocognition and daily-functioning. It is unknown whether these associations extend to disorders characterized by poor neurocognition, such as schizophrenia. Therefore, we compared AF and BMI in individuals with schizophrenia and non-clinical controls, and then within the schizophrenia group we examined the links between AF, BMI, neurocognition and daily-functioning. Thirty-two individuals with schizophrenia and 64 gender- and age-matched controls completed assessments of AF (indexed by VO2max) and BMI. The former also completed measures of neurocognition, daily-functioning and physical activity. The schizophrenia group displayed significantly lower AF and higher BMI. In the schizophrenia group, AF was significantly correlated with overall neurocognition (r=0.57), along with executive functioning, working memory, social cognition, and processing speed. A hierarchical regression analysis indicated that AF accounted for 22% of the neurocognition variance. Furthermore, AF was significantly correlated with overall daily-functioning (r=0.46). In contrast, BMI displayed significant inverse correlations with neurocognition, but no associations to daily-functioning. AF was significantly correlated physical activity. The authors discuss the potential use of AF-enhancing interventions to improve neurocognitive and daily-functioning in schizophrenia, along with putative neurobiological mechanisms underlying these links, including Brain-Derived Neurotrophic Factor.

Olanzapine-activated AMPK signaling in the dorsal vagal complex is attenuated by histamine H1 receptor agonist in female rats

Weight gain and its related metabolic disorders are major side effects associated with second generation antipsychotic drug treatment. The dorsal vagal complex (DVC) and AMP-activated protein kinase (AMPK) are implicated in the regulation of food intake and body weight. Blocking the histamine H1 receptor contributes to antipsychotic-induced weight gain. The present study investigated the time-dependent effect of olanzapine treatment (8, 16, and 36 d) on DVC AMPK signaling in olanzapine-induced weight gain and whether these changes are associated with olanzapine-induced H1 receptor antagonism. During the 8-day olanzapine treatment, the rats were hyperphagic and rapidly gained weight. The phosphorylation of AMPK (pAMPK) (activated AMPK) as well as its directly downstream phospho-acetyl-coenzyme A carboxylase was significantly increased. The pAMPK/AMPK ratio, an indicator of AMPK activity, was significantly positively correlated with feeding efficiency and weight gain. As treatment was prolonged (16 and 36 d of olanzapine treatment), the rats were no longer hyperphagic, and there were no longer any changes in DVC AMPK signaling. Although the DVC H1 receptor protein expression was not significantly altered by olanzapine, the pAMPK expression was significantly positively correlated with the H1 receptor level after the 8-, 16-, and 36-day olanzapine treatments. Moreover, we showed that an H1 receptor agonist, 2-(3-trifluoromethylphenyl) histamine, significantly inhibited the olanzapine-induced hyperphagia and DVC AMPK activation in a dose-dependent manner. These results suggest a time-dependent role of DVC AMPK in olanzapine-induced obesity. Thus, olanzapine-induced DVC AMPK activation may be at least partially related to olanzapine's antagonistic effect on the H1 receptor.

Selection, use and psychometric properties of physical activity measures to assess individuals with severe mental illness: a narrative synthesis

This research provides a critical consideration of the outcome measures used to assess physical activity in individuals with severe mental illness. A narrative synthesis was utilised to provide a simple juxtapose of the current research. A sensitive topic-based search strategy was conducted in order to identify studies that met the eligibility criteria. Fifty two studies met the inclusion criteria and 5 were identified specially as validation studies. The current research identified several methodological shortcomings. The justification and choice of outcome measure used is often weak and only five studies have validated a specific outcome measure of physical activity. Within these validation studies, the validation process often lacked a consideration of agreement between measures. Accelerometers have been most frequently used as a criterion measure, notably the RT3 tri-axial accelerometer. Objective based measures may be best placed to consider physical activity levels, although, methodological considerations for the utilization of such tools is required. Self-report questionnaires have benefits for use in this population but require further validation. Researchers and clinicians need to carefully consider what outcome measure they are using and be aware of the development, scope and purpose of that measure.

Visceral obesity in normal-weight patients suffering from chronic schizophrenia

BACKGROUND

BMI (body mass index) can be misleading regarding the level of adiposity in a normal-weight individual. Recently, a bioelectrical impedance analysis (BIA) method was developed that can measure body composition variables. The main objectives of this study were to use BIA to compare the body composition variables between chronic non-diabetic schizophrenic patients with normal weight and healthy individuals. The secondary objective was to compare the nutritional pattern of schizophrenia patients with that of matched healthy subjects, and to identify possible relationships between the content of different components of their diet and visceral adiposity.

METHODS

The subjects were 52 normal-weight patients (33 males and 19 females) diagnosed with schizophrenia based on the DSM-IV and 45 (23 males and 22 females) BMI- matched controls. The patients had been receiving atypical or typical antipsychotic agents for at least one year before enrollment into the study but continuously for 3 months preceding the study and were psychiatrically stable. Body fat (kg), percent (%) body fat, fat-free mass, VAT (visceral adipose tissue) and SAT (subcutaneous adipose tissue) were measured using the bioelectrical impedance analysis (BIA) method. Daily food rations (DFR) were quantitatively evaluated by a 24-h dietary recall method covering 3 days preceding the examination.

RESULTS

In normal-weight patients schizophrenia was significantly linked with higher VAT, VAT/SAT ratio and lower fat- free mass. Men had over 5 times and women over 2 times as much VAT as BMI matched groups. In women with schizophrenia and in their controls, the amount of magnesium, niacin and vitamin B6 in their diet inversely correlated with VAT, while in men lower zinc and vitamin C intake was related to higher visceral adiposity.

CONCLUSIONS

Our study has shown that normal-weight patients with chronic schizophrenia have higher levels of visceral fat (VAT) than controls but similar volume of subcutaneous adipose tissue (SAT). Although no clear conclusion can be made regarding cause-and-effect relationships between the dietary content of food served to our patients and visceral obesity, we suggest that schizophrenia diet should be further investigated as a possible factor related to this type of obesity.

Eating disorders in schizophrenia: implications for research and management

Objective. Despite evidence from case series, the comorbidity of eating disorders (EDs) with schizophrenia is poorly understood. This review aimed to assess the epidemiological and clinical characteristics of EDs in schizophrenia patients and to examine whether the management of EDs can be improved. Methods. A qualitative review of the published literature was performed using the following terms: "schizophrenia" in association with "eating disorders," "anorexia nervosa," "bulimia nervosa," "binge eating disorder," or "night eating syndrome." Results. According to our literature review, there is a high prevalence of comorbidity between schizophrenia and EDs. EDs may occur together with or independent of psychotic symptoms in these patients. Binge eating disorders and night eating syndromes are frequently found in patients with schizophrenia, with a prevalence of approximately 10%. Anorexia nervosa seems to affect between 1 and 4% of schizophrenia patients. Psychopathological and neurobiological mechanisms, including effects of antipsychotic drugs, should be more extensively explored. Conclusions. The comorbidity of EDs in schizophrenia remains relatively unexplored. The clearest message of this review is the importance of screening for and assessment of comorbid EDs in schizophrenia patients. The management of EDs in schizophrenia requires a multidisciplinary approach to attain maximized health outcomes. For clinical practice, we propose some recommendations regarding patient-centered care.

The importance of self-determined motivation towards physical activity in patients with schizophrenia

There is a need for theoretically-based research on the motivational processes linked to the commencement and continuation of physical activity in patients with schizophrenia. Within the Self-Determination Theory (SDT) framework, we investigated the SDT tenets in these patients by examining the factor structure of the Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) and by investigating associations between motivation and PA. The secondary aim was to study differences in motivation according to gender, educational level, treatment setting and disease stage. A total of 129 patients (44♀) with schizophrenia agreed to participate. Exploratory factor analysis showed sufficient convergence with the original factor for amotivation, external and introjected regulation, while identified and intrinsic regulations loaded on a single factor which we labeled "autonomous regulation". Significant positive correlations were found between the total physical activity score and the subscales amotivation (r = -0.44, P < 0.001), external regulation (r = -0.27, P < 0.001), and autonomous regulation (r = 0.57, P < 0.001). Outpatients reported more external (P < 0.05) and introjected (P < 0.05) regulations than inpatients. Our results suggest that patients' level of self-determination may play an important role in the adoption and maintenance of health promoting behaviors in patients with schizophrenia.

Effects of risperidone on energy balance in female C57BL/6J mice

OBJECTIVE

To investigate the effect of risperidone on energy expenditure and weight gain in female C57BL/6J mice.

DESIGN AND METHODS

Body weight and composition, food intake, energy expenditure, and activity were determined weekly. mRNA expression of uncoupling protein 1 in brown adipose tissue, orexin, and brain-derived neurotrophic factor in the hypothalamus were quantified using real-time PCR.

RESULTS

Risperidone tended to induce a greater body weight gain (P = 0.052) and significantly higher food intake (P = 0.038) relative to the placebo-treated group. Risperidone-treated mice had a higher resting energy expenditure (P = 0.001) and total energy expenditure (TEE) (P = 0.005) than the placebo group. There were no effects of treatment, time, and treatment by time on non-resting (or activity-related) energy expenditure between groups. Risperidone-treated mice showed a significantly lesser locomotor activity than placebo-treated mice over 3 weeks (P < 0.001). Risperidone induced a higher UCP1 mRNA (P = 0.003) and a lower orexin mRNA (P = 0.001) than placebo.

CONCLUSION

Risperidone-induced weight gain is associated with hyperphagia and a reduction in locomotor activity in C57BL/6J mice. Additionally, higher total and resting energy expenditure were accompanied by higher levels of UCP1 mRNA in BAT. The increased TEE could not offset the total intake of energy through risperidone-induced hyperphagia, therefore resulting in weight gain in female C57BL/6J mice.

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.

Associations between sedentary behaviour and metabolic parameters in patients with schizophrenia

This study examined the association between sedentary behaviour and metabolic parameters among patients with schizophrenia. A total of 76 patients and 38 healthy age-, gender- and BMI-matched volunteers were included. Participants were asked for their overall sitting and physical activity behaviour using the International Physical Activity Questionnaire. Patients were additionally screened for psychiatric symptoms and extrapyramidal side-effects of antipsychotic medication. On average, patients with schizophrenia spent 8.5h per day sitting (versus 6.21h in healthy controls). Patients sitting more than 10.4h per day had a higher BMI, waist circumference and fasting glucose concentrations and experienced more negative and cognitive symptoms than those sitting less than 5.8h per day. Overall sitting time was associated with a significantly greater likelihood of metabolic syndrome. A stepwise backward-elimination multivariate regression analysis demonstrated that sitting time is a significant predictor for BMI. Current results suggest patients with schizophrenia may benefit from reducing total sitting time.

Are there different neural mechanisms responsible for three stages of weight gain development in anti-psychotic therapy: temporally based hypothesis

Weight gain as a result of atypical anti-psychotic treatment is a common issue with different atypical anti-psychotic treatments causing differing magnitudes of weight gain. Although differing amounts of weight gain result from different atypical agents little is known about the temporal course of weight gain in anti-psychotic treatment. Specifically is the time course of weight gain comparable across different agents. Therefore this article reviews the temporal course of weight gain for three common atypical anti-psychotics namely; clozapine, olanzapine and risperidone. It is evident that all three of these agents exhibit similar although at distinct magnitudes temporal courses of weight gain. That is an initial rapid increase from baseline to 3 months (stage 1), a steady increase from 3 months to 18 months (stage 2) and a plateau after this point (stage 3) with continued anti-psychotic treatment. It is postulated that each of these stages of weight gain result from distinct neural mechanisms. The hypothesized neural correlates for each stage of weight gain are reviewed and discussed. The article concludes with recommendations for future research.

A systematic review of correlates of physical activity in patients with schizophrenia

OBJECTIVE

The present review evaluates systematically the published quantitative studies of correlates of PA in patients with schizophrenia.

METHOD

EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL and PEDro were searched from their inception to 1 July 2011 combining the medical subject heading 'schizophrenia' with 'physical activity' or 'physical inactivity' or 'exercise' or 'health education' or 'health behaviour' or 'health promotion'.

RESULTS

Out of 68 potentially eligible studies, 25 papers (n = 25,013) evaluating 36 correlates were included. Correlates consistently associated with lower PA participation are the presence of negative symptoms and cardio-metabolic comorbidity. Also, side-effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self-efficacy, other unhealthy lifestyle habits and social isolation correlated with lower PA participation. The quality of the PA measurement was not related to the proportion of significant associations (χ(2) = 3.8, P = 0.07). Current gaps in literature that need to be examined more in detail are the role of environmental and policy-level factors on PA participation in patients with schizophrenia.

CONCLUSION

All correlates should be confirmed in prospective studies, and interventions to improve the modifiable variables should be developed and evaluated.

Feasibility of pedometers for adults with schizophrenia: pilot study

The purpose of this prospective and observational design study was to assess the feasibility of using a pedometer and step log to explore level of physical activity (PA) and to assess motivation to be physically active in adults with schizophrenia. Descriptive statistics were used to analyse data of 7 male and 5 female subjects. Pedometer data indicated that subjects walked an average of 4731.03 (±3318.19) steps and 5002.58 (±3041.03) during the first week and second week of the study, respectively. A minimum 30-min walk was recorded on an average of 3.67 (±1.82) days (week one) and 4.5 (±1.88) days (week two). Step logs, inconsistently maintained by subjects, were not able to be analysed. Examination of the Motives for Physical Activity Measure-Revised (MPAM-R) at baseline indicates that exercise fitness and body appearance were subjects' primary motives for PA participation. Study findings indicate that it is feasible to use a pedometer to monitor the level of PA. However, maintenance of a concurrent step log requires further consideration to determine realistic outcomes. Extrinsically focused motivations for PA in this study sample may predict low PA adherence.

Relationships between obesity, functional exercise capacity, physical activity participation and physical self-perception in people with schizophrenia

OBJECTIVE

This study compared differences in functional exercise capacity between patients with schizophrenia and healthy controls. Physical self-perception and physical activity variables contributing to the variability in the distance achieved during a walk test were identified.

METHOD

A total of 25 normal weight, 25 overweight and 10 obese patients and 40 healthy volunteers were included. Functional exercise capacity was explored with a 6-minute walk test. Level of physical activity was assessed using the Baecke questionnaire and physical self-perception using the physical self-perception profile.

RESULTS

Obese patients walked a significantly shorter distance than overweight and normal weight patients (450.6 ± 97.7, 580.2 ± 116.0 and 615.8 ± 92.4 m resp., P < 0.001). All patients walked a shorter distance than healthy controls (710.6 ± 108.4 m, P < 0.001). Dyspnoea was only prevalent in schizophrenia (28.3%, P < 0.001) and especially in obese patients (90% vs. 40% in overweight and 27.3% in normal weight patients, P < 0.001). In multiple regression analysis, 59% of the variance in walking distance was explained by body mass index, perceived sports competence and condition, physical self-worth, level of sports participation and smoking behaviour.

CONCLUSION

Functional exercise capacity in patients with schizophrenia is reduced not only by obesity, perceived discomfort and pain but also by a sedentary, unhealthy life style and a reduced physical self-perception.

Influence of resting energy expenditure on weight gain in adolescents taking second-generation antipsychotics

BACKGROUND & AIMS

Weight gain is an undesirable side effect of second-generation antipsychotics (SGAs). We performed this study to examine the influence of SGAs on resting energy expenditure (REE) and the relationship of REE to weight gain in adolescent patients.

METHODS

Antipsychotic-naïve or quasi-naïve (<72 h of exposure to antipsychotics) adolescent patients taking olanzapine, quetiapine, or risperidone in monotherapy were followed up for one year. We performed a prospective study (baseline, 1, 3, 6, and 12 months after treatment) based on anthropometric measurements, bioelectrical impedance analysis, and indirect calorimetry (Deltatrac™ II MBM-200) to measure REE. We also analyzed metabolic and hormonal data and adiponectin concentrations.

RESULTS

Forty-six out of the 54 patients that started treatment attended at least 2 visits, and 16 completed 1 year of follow-up. Patients gained 10.8 ± 6.2 kg (60% in the form of fat mass) and increased their waist circumference by 11.1 ± 5.0 cm after 1 year of treatment. The REE/kg body mass ratio decreased (p = 0.027), and the REE/percentage fat-free mass (FFM) ratio increased (p = 0.007) following the fall in the percentage of FFM during treatment. Weight increase was significantly correlated with the REE/percentage FFM ratio at all the visits (1-3-6-12 months) (r = 0.69, p = 0.004 at 12 months).

CONCLUSIONS

SGAs seem to induce a hypometabolic state (reflected as decreased REE/kg body mass and increased REE/percentage FFM). This could explain, at least in part, the changes in weight and body composition observed in these patients.

Low cardiorespiratory fitness and physical functional capacity in obese patients with schizophrenia

BACKGROUND

Low cardiorespiratory fitness is a prominent behavioral risk factor for cardiovascular disease (CVD) morbidity and mortality, as cardiorespiratory fitness is strongly associated with CVD outcomes. High rates of CVD have been observed in the schizophrenia population, translating into a markedly reduced life expectancy as compared to healthy controls. Surprisingly however, while cardiorespiratory fitness is an eminent indicator for overall cardiovascular health as well as eminently modifiable risk factor for CVD, no studies have systematically assessed cardiorespiratory fitness in schizophrenia.

METHODS

Community-dwelling schizophrenia patients underwent graded-exercise tests, to ascertain maximal oxygen uptake (Max Vo2), considered to be the gold standard for the evaluation of cardiorespiratory fitness and physical functional capacity. The modified Bruce protocol was used to ascertain cardiorespiratory fitness and physical functional capacity; data was normalized and compared to population standards derived from the ACLS (Aerobics Center Longitudinal Study) and the National Health and Nutrition Examination Surveys (NHANES), Cycles III and IV.

RESULTS

Data for n=117 participants (41% male, 46% white) was analyzed. Mean age (y) was 43.2±9.9, and mean BMI was 37.2±7.3. Peak HR attained during exercise was 145.6±19.6, after 8.05±3.6 min, achieving 111.2±44.2W. Max Vo2 was 1.72±6.6l/min, MaxVCo2 1.85±7.2l/min, and minute ventilation (VE) was 55.6±21.9 ml/s. PANSS Positive subscores (13.3±4.4; r=-0.21, p=0.024) were inversely correlated with Max Vo2 ml(-1)min(-1) kg(-1). Neither PANSS Total (56.3±12.3; r=-0.105, p=0.72), PANSS Negative (14±5.1; r=-0.52, p=0.57) nor PANSS General Psychopathology (28.4±7.4; r=-0.28, p=0.76) scores were correlated with Max Vo2 ml(-1) min(-1) kg(-1). Peak heart rate and duration of exercise were not correlated with PANSS scores. Compared to healthy controls derived from the ACLS and NHANES, respectively, 115 participants achieved 'low levels' of fitness only, as well as highly significantly reduced Max Vo2, across all age groups.

CONCLUSION

The test was generally well received and tolerated by those who elected to participate; and adherence to the protocol was good. Among participants with schizophrenia, most of whom were obese, and across all age groups, cardiorespiratory fitness was exceedingly poor. Only two participants in our entire sample fit the categorization of 'moderate fitness level'; that is, a fitness level at or above the 20th percentile of ACLS-derived population comparisons. Conversely, this left 98.3% of participants with schizophrenia below population standards. Low cardiorespiratory fitness emerges as an eminent modifiable risk factor for CVD mortality and morbidity in schizophrenia complicated by obesity.

Antipsychotic drugs and obesity

Mechanisms underlying antipsychotic cardiometabolic adverse effects are incompletely understood. This hampers the identification of high-risk patients, low-risk antipsychotics and preventive/ameliorative treatments. Recent clinical, molecular and genetic data suggest that: (i) antipsychotic-naïve samples provide the greatest power for mechanistic studies; (ii) weight and metabolic effects can be discordant, pointing to overlapping and distinct mechanisms; (iii) antipsychotics affect satiety and energy homeostasis signaling; (iv) the specific peptides mediating these effects are unknown but probably overlap with those involved in idiopathic obesity; and (v) single nucleotide polymorphisms in genes encoding known neurotransmitter receptors and metabolic proteins are promising pharmacogenomic targets for countering adverse affects. However, sophisticated molecular studies and genome-wide association studies, ideally in antipsychotic-naïve/first episode samples, are needed to further advance the field.

Physical capacity, respiratory quotient and energy expenditure during exercise in male patients with schizophrenia compared with healthy controls

BACKGROUND

Despite massive research on weight gain and metabolic complications in schizophrenia there are few studies on energy expenditure and no current data on physical capacity.

AIM

To determine oxygen uptake capacity, respiratory quotient (RQ) and energy expenditure during a submaximal exercise test in patients with schizophrenia and healthy controls.

METHOD

Ten male patients and 10 controls were included. RQ and energy expenditure were investigated with indirect calorimetry during a cycle ergometer test. The submaximal work level was defined by heart rate and perceived exhaustion. Physical capacity was determined from predicted maximal oxygen uptake capacity (VO(2-max)).

RESULTS

The patients exhibited significantly higher RQ on submaximal workloads and lower physical capacity. A significant lower calculated VO(2-max) remained after correction for body weight and fat free mass (FFM). Energy expenditure did not differ on fixed workloads.

CONCLUSION

RQ was rapidly increasing in the patients during exercise indicating a faster transition to carbohydrate oxidation and anaerobic metabolism that also implies a performance closer to maximal oxygen uptake even at submaximal loads. This may restrict the capacity for everyday activity and exercise and thus contribute to the risk for weight gain. Physical capacity was consequently significantly lower in the patients.

Management of antipsychotic-related weight gain

Despite variations across individuals and agents, antipsychotics are associated with clearly documented weight gain and adverse metabolic effects. Although increased appetite/caloric intake and various receptors, hormones and peptides have been implicated, biological mechanisms contributing to the increase in weight and glucose and lipid abnormalities with antipsychotics are largely unknown. This has hampered the creation of antipsychotics that are free of cardiometabolic effects, even in antipsychotic-naive/early-phase patients, as well as the development of strategies that can prevent or drastically diminish the adverse cardiometabolic effects. In general, three strategies can reduce the cardiometabolic risk of antipsychotics: switching to a less orexigenic/metabolically adverse antipsychotic; adjunctive behavioral treatments; and adjunctive pharmacologic interventions. However, each of these strategies has only been shown to be modestly effective. Among different behavioral interventions (N = 14, n = 746), group and individual treatment, dietary counseling and cognitive-behavioral therapy seem to be similarly effective. Among 15 different pharmacologic strategies (N = 35, n = 1629), only metformin, fenfluramine, sibutramine, topiramate and reboxetine were more effective than placebo, with the most evidence being available for metformin, and no head-to-head trials comparing individual pharmacologic interventions. However, even in the most successful trials the risk reduction was modest. Weight was not decreased to a pretreatment level, and despite superiority compared with placebo, weight gain still often occurred, particularly in antipsychotic-naive patients and when interventions were 'preventively' coinitiated with antipsychotics. Future research should focus on combining treatment modalities or agents and on exploring novel mechanism-based interventions.

The potential role of appetite in predicting weight changes during treatment with olanzapine

BACKGROUND

Clinically significant weight gain has been reported during treatment with atypical antipsychotics. It has been suggested that weight changes in patients treated with olanzapine may be associated with increased appetite.

METHODS

Data were used from adult patients for whom both appetite and weight data were available from 4 prospective, 12- to 24-week clinical trials. Patients' appetites were assessed with Eating Behavior Assessment (EBA, Study 1), Platypus Appetite Rating Scale (PARS, Study 2), Eating Inventory (EI, Study 3), Food Craving Inventory (FCI, Study 3), and Eating Attitude Scale (EAS, Study 4).

RESULTS

In Studies 1 (EBA) and 4 (EAS), patients who reported overall score increases on appetite scales, indicating an increase in appetite, experienced the greatest overall weight gains. However, in Studies 2 (PARS) and 3 (EI, FCI), patients who reported overall score increases on appetite scales did not experience greater weight changes than patients not reporting score increases. Early weight changes (2-4 weeks) were more positively correlated with overall weight changes than early or overall score changes on any utilized appetite assessment scale. No additional information was gained by adding early appetite change to early weight change in correlation to overall weight change.

CONCLUSIONS

Early weight changes may be a more useful predictor for long-term weight changes than early score changes on appetite assessment scales.

CLINICAL TRIALS REGISTRATION

This report represents secondary analyses of 4 clinical studies. Studies 1, 2, and 3 were registered at http://clinicaltrials.gov/ct2/home, under NCT00190749, NCT00303602, and NCT00401973, respectively. Study 4 predates the registration requirements for observational studies that are not classified as category 1 observational studies.

Antipsychotics associated with the development of type 2 diabetes in antipsychotic-naïve schizophrenia patients

Diabetes mellitus occurs in schizophrenia patients at higher rates than in the general population. Reasons for this elevated risk are poorly understood and have not been examined prospectively in antipsychotic-naïve, first-episode patients. This study aims to determine which antipsychotics are associated with diabetes development in antipsychotic-naïve schizophrenia patients. All antipsychotic-naïve patients diagnosed with schizophrenia in Denmark between 01 January 1997 and 31 December 2004, followed until 31 December 2007, allowing for >or=3 years follow-up, unless death or diabetes onset occurred. Risk factors for the time to diabetes onset were assessed, including antipsychotics taken for at least 180 defined daily doses in the first year after first antipsychotic prescription ('initial treatment'). Risk factors for diabetes incidence were assessed, including antipsychotic use within 3 months before diabetes onset or study end ('current treatment'). Of 7139 patients, followed for 6.6 years (47,297 patient years), 307 developed diabetes (annual incidence rate: 0.65%). Time to diabetes onset was significantly shorter in patients with higher age (hazard ratio (HR): 1.03, confidence interval (CI): 1.02-1.03) and those with 'initial' treatment of olanzapine (HR: 1.41, CI: 1.09-1.83), mid-potency first-generation antipsychotics (FGAs) (HR: 1.60, CI: 1.07-2.39), antihypertensive (HR: 1.87, CI: 1.13-3.09), or lipid-lowering drugs (HR: 4.67, CI: 2.19-10.00). Significant factors associated with diabetes within 3 month of its development included treatment with low-potency FGAs (odds ratio (OR): 1.52, CI: 1.14-2.02), olanzapine (OR: 1.44, CI: 1.98-1.91), and clozapine (OR: 1.67, CI: 1.14-2.46), whereas aripiprazole was associated with lower diabetes risk (OR: 0.51, CI: 0.33-0.80). In addition to general diabetes risk factors, such as age, hypertension, and dyslipidemia, diabetes is promoted in schizophrenia patients by initial and current treatment with olanzapine and mid-potency FGAs, as well as by current treatment with or low-potency first-generation antipsychotics and clozapine, whereas current aripiprazole treatment reduced diabetes risk. Patients discontinuing olanzapine or mid-potency FGA had no increased risk of diabetes compared with patient not treated with the drugs at anytime.

Considering a frame of reference for physical activity research related to the cardiometabolic risk profile in schizophrenia

This article reviews evidence that researchers and mental health service providers need to take into account four modifiable factors that affect the prevalence of the metabolic syndrome in people with schizophrenia: (a) physical activity as part of a health-related lifestyle, (b) physical fitness, (c) mental health status and (d) antipsychotic medication. The implementation of physical activity in order to prevent and treat cardiometabolic risk factors in people with schizophrenia is discussed. English language articles published until July 2009 were identified by PubMed, CINAHL, PsychINFO, and Cochrane Central Register of Controlled Trials. The search terms schizophrenia and metabolic syndrome, physical activity, health, fitness, and lifestyle were used. Physical activity interventions result in positive effects on metabolic outcomes, physical fitness, health-related behavior and mental health. Considering present knowledge, physical therapists should take into account the emotional (negative symptoms, self-esteem, self-efficacy, and stress) and physiological (cardiometabolic parameters) components of mental illness when offering physical activity interventions. The physical activity stimulus should be adapted to the individual's physical fitness level and the side effects of the antipsychotic medications. More research is needed to assist in the practical development of effective evidence-based preventive and curative strategies in psychiatric services for metabolic syndrome in persons with schizophrenia.

The place and promotion of well-being in mental health services: a qualitative investigation

The study investigated the place and promotion of well-being from the perspectives of services users and mental health professionals. * Data from focus groups and interviews were analysed and found that well-being promotion was available, for example weight management groups in mental health services. However, they also found that there were some contradictions between the groups of people interviewed about what was available and what to promote in the future. * The study concludes suggesting partnerships with local communities to further develop well-being services, such as opportunities for physical activity, for people with mental health problems. Abstract This study explored service users' and mental health professionals' understandings, experiences and opinions of well-being and its promotion within mental health services. A qualitative case study methodology included nine participants (five adult service users, three mental health professionals, one senior manager) who were purposively sampled from a Mental Health Trust in England. Service users participated in a focus group, while individual semi-structured interviews were held with the mental health professionals and senior manager. Interpretative phenomenological analysis of the data revealed five main themes including well-being as a holistic concept; well-being promotion; the place, promotion and position of well-being; role of mental health services in well-being promotion; and areas for further improvement. Findings revealed evidence of well-being promotion; however, there were contradictions regarding what was known between the groups of participants and what could be provided in the future. Implications for practice include the need to establish more effective partnership working between mental health services and local communities, especially in light of financial constraints within health services at large. This could assist the increased provision of therapeutic services for well-being promotion.

The impact of antipsychotic drugs on food intake and body weight and on leptin levels in blood and hypothalamic ob-r leptin receptor expression in wistar rats

OBJECTIVES

The aim of our study was to investigate the impact of typical and atypical antipsychotic drugs on leptin concentration in blood and changes in the receptor expression in the hypothalamus of male Wistar rats.

METHODS

From the age of 13 to 18 weeks, three groups of 20 animals were fed an average dose of 3.5 + 0.03 mg/ kg body weight (BW) haloperidol; 30.6 + 0.22 mg/kg BW clozapine; or 14.9 + 0.13 mg/kg BW ziprasidone in ground food pellets containing 15% fat. Twenty control animals received no drugs. Blood samples were taken at week 14, 16, and 19. Locomotor activity and exploratory behavior were measured using the alcove test at weeks 15 and 17. The expression of the hypothalamic leptin receptor in rat brains was determined by using a Western blot.

RESULTS

Rats medicated with haloperidol and ziprasidone showed a significantly decreased percentage weight gain and food consumption. We observed no differences in the alcove test, but locomotor activity was significantly reduced in the haloperidol group. Except for rats in the clozapine and ziprasidone groups, after 2 weeks of drug application, we found no changes in the leptin blood concentrations among the four groups or animals within each group. Moreover, we did not find specific differences in hypothalamic leptin receptor expression among the groups.

CONCLUSION

We concluded that in male Wistar rats during this treatment period, the tested drugs did not act directly on the leptin regulatory system. We recommend further studies using long-term treatment of different rat strains.

Low-fat oxidation may be a factor in obesity among men with schizophrenia

OBJECTIVE

Obesity associated with atypical antipsychotic medications is an important clinical issue for people with schizophrenia. The purpose of this project was to determine whether there were any differences in resting energy expenditure (REE) and respiratory quotient (RQ) between men with schizophrenia and controls.

METHOD

Thirty-one men with schizophrenia were individually matched for age and relative body weight with healthy, sedentary controls. Deuterium dilution was used to determine total body water and subsequently fat-free mass (FFM). Indirect calorimetry using a Deltatrac metabolic cart was used to determine REE and RQ.

RESULTS

When corrected for FFM, there was no significant difference in REE between the groups. However, fasting RQ was significantly higher in the men with schizophrenia than the controls.

CONCLUSION

Men with schizophrenia oxidised proportionally less fat and more carbohydrate under resting conditions than healthy controls. These differences in substrate utilisation at rest may be an important consideration in obesity in this clinical group.

Hyperphagia and increased meal size are responsible for weight gain in rats treated sub-chronically with olanzapine

RATIONALE

Atypical antipsychotic-induced weight gain is a significant impediment in the treatment of schizophrenia.

OBJECTIVES

In a putative model of antipsychotic drug-induced weight gain, we investigated the effects of sub-chronic olanzapine on body weight, meal patterns, the expression of genes encoding for hypothalamic feeding-related neuropeptides and the contribution of hyperphagia to olanzapine-induced weight gain in rats.

MATERIALS AND METHODS

In experiment 1, female rats received either olanzapine (1 mg/kg, p.o.) or vehicle, twice daily for 7 days, while meal patterns were recorded. At the end of the treatment regimen, we measured the levels of hypothalamic messenger RNAs (mRNAs) encoding neuropeptide-Y (NPY), hypocretin/orexin (HCRT), melanin concentrating hormone and pro-opiomelanocortin. NPY and HCRT mRNA levels were also assessed in a separate cohort of female rats treated acutely with olanzapine (1 mg/kg, p.o.). In experiment 2, we investigated the effect of a pair-feeding paradigm on sub-chronic (1 mg/kg, p.o.) olanzapine-induced weight gain.

RESULTS

In experiment 1, sub-chronic olanzapine increased body weight, food intake and meal size. Hypothalamic neuropeptide mRNA levels were unchanged after both acute and sub-chronic olanzapine treatment. In experiment 2, the restriction of food intake to the level of vehicle-treated controls abolished the sub-chronic olanzapine-induced increase in body weight.

CONCLUSIONS

Hyperphagia mediated by drug-induced impairments in satiety (as evidenced by increased meal size) is a key requirement for olanzapine-induced weight gain in this paradigm. However, olanzapine-induced hyperphagia and weight gain may not be mediated via alterations in the expression of the feeding-related hypothalamic neuropeptides examined in this study.

The role of thermogenesis in antipsychotic drug-induced weight gain

The administration of antipsychotic drugs to human patients or experimental animals leads to significant weight gain, which is widely presumed to be driven by hyperphagia; however, the contribution from energy expenditure remains unclear. These studies aim to examine the contribution of shifts in energy expenditure, particularly those involving centrally mediated changes in thermogenesis, to the body weight gain associated with the administration of olanzapine to female Sprague Dawley rats. Olanzapine (6 mg/kg/day orally) caused a transient increase in food intake but a maintained increase in body weight. When pair-fed rats were treated with olanzapine, body weight continued to rise compared to vehicle-treated rats, consistent with a reduction in energy expenditure. Brown adipose tissue (BAT) temperature, measured using biotelemetry devices, decreased immediately after the onset of olanzapine treatment and remained depressed, as did physical activity. UCP1 expression in interscapular BAT was reduced following chronic olanzapine treatment. An acute injection of olanzapine was preceded by an injection of a retrograde tracer into the spinal cord to evaluate the nature of the olanzapine-activated neural pathway. Levels of Fos protein in a number of spinally projecting neurons within discrete hypothalamic and brainstem sites were elevated in olanzapine-treated rats. Some of these neurons in the perifornical region of the lateral hypothalamus (LHA) were also Orexin A positive. These data collectively show a significant impact of thermogenesis (and physical activity) on the weight gain associated with olanzapine treatment. The anatomical studies provide an insight into the central neuroanatomical substrate that may subserve the altered thermogenic responses brought about by olanzapine.

Predicting transitory mood from physical activity level among people with severe mental illness in two cultures

BACKGROUND

Previous studies have indicated that physical activity (PA) is positively related to health-related quality of life and well-being among people with severe mental illness (SMI). Physical activity is broadly defined in this research as any skeletal muscle movement resulting in energy expenditure, including common daily activities such as housework and gardening, as well as walking for transportation and formal exercise. Although the physical health benefits of PA are well documented, evidence suggests that PA provides psychological benefits as well.

AIMS

The purpose of this study was to identify if PA level was associated with transitory mood in the everyday lives of people with SMI across two cultures.

METHODS

Subjects were drawn through mental health centres in Serbia (n = 12) and the USA (n = 11). Data were collected using both experience sampling methodology and accelerometry. Data were analyzed using hierarchical linear modelling.

RESULTS

Subjects demonstrated low levels of PA, which did not differ significantly between groups. Hierarchical analysis indicated that PA remained significantly positively associated with mood after accounting for individual variation, and this was consistent across groups.

CONCLUSIONS

This study reinforces previous findings that people with SMI demonstrate low PA levels generally. It also supports the consideration of physical activity interventions as a regular part of psychiatric rehabilitation. It appears that increased PA may have the potential to affect both physical health and mood among people with SMI.

Pharmacological management of atypical antipsychotic-induced weight gain

Excessive bodyweight gain was reported during the 1950s as an adverse effect of typical antipsychotic drug treatment, but the magnitude of bodyweight gain was found to be higher with the atypical antipsychotic drugs that were introduced after 1990. Clozapine and olanzapine produce the greatest bodyweight gain, ziprasidone and aripiprazole have a neutral influence, and quetiapine and risperidone cause an intermediate effect. In the CATIE study, the percentage of patients with bodyweight gain of >7% compared with baseline differed significantly between the antipsychotic drugs, i.e. 30%, 16%, 14%, 12% and 7% for olanzapine, quetiapine, risperidone, perphenazine (a typical antipsychotic) and ziprasidone, respectively (p<0.001). Appetite stimulation is probably a key cause of bodyweight gain, but genetic polymorphisms modify the bodyweight response during treatment with atypical antipsychotics. In addition to nutritional advice, programmed physical activity, cognitive-behavioural training and atypical antipsychotic switching, pharmacological adjunctive treatments have been assessed to counteract excessive bodyweight gain. In some clinical trials, nizatidine, amantadine, reboxetine, topiramate, sibutramine and metformin proved effective in preventing or reversing atypical antipsychotic-induced bodyweight gain; however, the results are inconclusive since few randomized, placebo-controlled clinical trials have been conducted. Indeed, most studies were short-term trials without adequate statistical power and, in the case of metformin, nizatidine and sibutramine, the results are contradictory. The tolerability profile of these agents is adequate. More studies are needed before formal recommendations on the use of these drugs can be made. Meanwhile, clinicians are advised to use any of these adjunctive treatments according to their individual pharmacological and tolerability profiles, and the patient's personal and family history of bodyweight gain and metabolic dysfunction.

Bioelectric impedance is a better indicator of obesity in men with schizophrenia than body mass index

Body mass index (BMI) is commonly used as an indicator of obesity, although in both clinical and research settings the use of bioelectric impedance analysis (BIA) is commonplace. The purpose of this study was to examine the relationship between BMI, BIA and percentage body fat to determine whether either is a superior indicator of obesity in men with schizophrenia. The reference method of deuterium dilution was used to measure total body water and, subsequently, percentage body fat in 31 men with schizophrenia. Comparisons with the classification of body fat using BMI and BIA were made. The correlation between percentage body fat and BMI was 0.64 whereas the correlation between percentage body fat and BIA was 0.90. The sensitivity and specificity in distinguishing between obese and overweight participants was 0.55 and 0.80 for BMI and 0.86 and 0.75 for BIA. BIA proved to be a better indicator of obesity than BMI. BMI misclassified a large proportion of men with schizophrenia as overweight when they had excess adiposity of sufficient magnitude to be considered as obese. Because of the widespread use of BMI as an indicator of obesity among people with schizophrenia, the level of obesity among men with schizophrenia may be in excess of that previously indicated.