Mortality among patients with schizophrenia

Type-2 diabetes mellitus in schizophrenia: Increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up

Objective

Physical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.

Methods

During 2000–2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.

Results

The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.

Conclusion

Schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Where are patients who have co-occurring mental and physical diseases located?

BACKGROUND

Patients with a psychiatric illness have a higher prevalence of physical diseases and thus a higher morbidity and mortality.

AIM

The main aim was to investigate where patients with co-occurring physical diseases and mental disorders (psychotic spectrum or mood) in the health and social service system are identified most frequently before admission into psychiatry. The second aim was to compare the differences in the treatment routes taken by the patients before entry into psychiatric services in all the participating countries (Denmark, Germany, Japan, Nigeria and Switzerland).

METHODOLOGY

On admission to a psychiatric service, patients diagnosed with schizophrenia, schizotypal or delusional disorders (International Classification of Diseases-10 (ICD-10) group F2) or mood (affective) disorders (ICD-10 group F3) and a co-morbid physical condition (cardiovascular disease, diabetes mellitus and overweight) were asked with which institutions or persons they had been in contact with in the previous 6 months.

RESULTS

Patients from Denmark, Germany and Switzerland with mental disorders had almost the same contact pattern. Their primary contact was to public or private psychiatry, with a contact percentage of 46%-91%; in addition, general practice was a common contact, with a margin of 41%-93%. Similar tendencies are seen in Japan despite the small sample size. With regard to general practice, this is also the case with Nigerian patients. However, religious guidance or healing was rarely sought by patients in Europe and Japan, while in Nigeria about 80% of patients with mental disorders had contacted this type of service.

CONCLUSION

Promoting prophylactic work between psychiatry and the general practice sector may be beneficial in diminishing physical conditions such as cardiovascular disease, diabetes mellitus and overweight in patients with mental disorders in European countries and Japan. In Nigeria (a low-to-middle-income country), religious guides or healers, along with general practitioners, are the most frequently contacted, and they therefore seem to be the most obvious partner to collaborate with.

Mortality of people suffering from mental illness: a study of a cohort of patients hospitalised in psychiatry in the north of France

BACKGROUND

The mortality of people suffering from psychiatric illnesses is far higher than that of the general population, all categories of diagnosis combined; mortality statistics can be used as an index of quality of care. The aim of this study was to assess the all-cause mortality in psychiatric patients covering all diagnostic groups.

METHODS

The living or deceased status of 4,417 patients of majority age hospitalised in a public mental health establishment between 2004 and 2007 were requested from French National Institute for Statistics and Economic Studies on 1st January 2011. The cause of death of those people who had died was obtained from French National Institute for Health and Medical Research and comparative standardized mortality ratios (SMR) were established from the population in a region of northern France of the same age in 2006.

RESULTS

The study population was made up of 54% men and 46% women, median age 41 and 45 years old, respectively. Four hundred and seventy-three people died during the period studied. The SMR were 421 for men (95% CI 378-470) and 330 for women (95% CI 281-388). The highest SMRs were found in patients aged 35-54, with a 20-time higher mortality risk than the general population of the same age.

CONCLUSION

Our study confirms the considerably higher mortality in psychiatric patients than in general population, particularly in mean age and mostly due to an unnatural cause.

[Deaths in a Tunisian psychiatric hospital: an eleven-year retrospective study]

BACKGROUND

Mortality in patients in psychiatric hospitals is reported to be two to three times as high as in the general population. In Tunisia, we do not have any figures on mortality and causes of death in psychiatric inpatients.

AIM

The aim of our study was to assess the mortality rate in a psychiatric hospital in comparison to the mortality rate in the general population, to determine the patients' profile, and to identify the causes and risk factors for these deaths.

METHODS

We performed a retrospective, descriptive and comparative study. We examined the records of all patients who died during their stay in the different wards of psychiatry at the Razi Hospital in Tunis. We also scrutinized reports of autopsies in the Forensic Medicine unit at Charles-Nicolle Hospital in Tunis over a period of eleven years from January 1st, 2000 to December 31st, 2010. We conducted a descriptive study to calculate the standardized mortality ratio (SMR) aiming to highlight any existing excess mortality among the psychiatric inpatients compared to the general population. This ratio was obtained by dividing the observed number of deaths by the expected number of deaths. In the analytical study, our sample was compared to a control population made-up of randomly selected living patients among those admitted to the Razi hospital in 2010. This study allowed us to investigate the risk factors for premature mortality in psychiatric inpatients.

RESULTS

The average rate of mortality was two deaths per 1000 inpatients per year. Twenty-four percent (24%) of deaths involved institutionalized patients. Compared to the general population, premature mortality was noted among patients aged less than 40 (SMR=1.9). The older the patients were, the closer to 1 the SMR was. The average age at death was 51.38 years; 65% of patients were male, 60% had a low socio-economic level, 54% had a comorbid medical condition. Forty-two percent (42%) of deceased patients were diagnosed with schizophrenia with the paranoid form being the most prevalent (44%), 13% had bipolar disorder, 22% had psycho-organic disorders (mental retardation, dementia, delirium). Antipsychotics were the most prescribed psychotropic drugs. High doses were used. Forty percent of cases (40%) consisted of sudden deaths. A cause for death was identified in 80% of cases. In 92% of cases, the death was classified as being "natural". Main causes were respiratory (26%) and cardiovascular (9%). Accidental causes accounted for 8% of deaths. In 20% of cases, the cause remained undetermined. Three factors were identified as independent predictors of mortality among mental patients: age at death (OR=3.9 among patients older than 40), psychiatric diagnosis (OR=2.9 among patients with psychotic or mood disorders compared to other diagnoses) and combination of antipsychotic drugs (OR=6.09 in patients receiving more than two antipsychotics).

DISCUSSION

Young psychiatric inpatients seem to be at high risk of premature death: the SMR in our study was 1.9. It ranged between 2.15 and 6.55 in other similar studies. This increased risk mainly concerns non-natural deaths. The leading natural cause of death in our population was represented by thromboembolic accidents. Such a high thromboembolic risk may be explained by the mental illness itself, by physical restraint as well as by antipsychotic treatment. Diagnosing medical conditions in psychiatric patients is often a daunting task: history of the patient is sometimes unreliable and clinical features might be modified by psychotropic agents. Patient-related risk factors for premature death include poor socio-economic level, access-to-care difficulties, positive family and personal history of mental and/or medical disorders, smoking, substance abuse, unhealthy diet and lack of physical activity. Moreover, iatrogenic effects of psychotropic drugs (combination of antipsychotics was more common in deceased patients than in controls) and inadequate medical care in psychiatric hospitals (lack of ECG devices, in particular) partly account for such a high mortality.

CONCLUSION

Identifying risk factors for deaths in psychiatric hospitals highlights needed changes in psychiatric management strategies taking into account the patient's characteristics as well as the drugs' safety profile. Further studies with larger samples are needed to better highlight risk factors for premature death in psychiatric inpatients. Identifying such risk factors is necessary to develop efficient preventive strategies.

Cultural diversity in physical diseases among patients with mental illnesses

OBJECTIVE

People with psychiatric diseases have a severely increased risk for physical morbidity and premature death from physical diseases. The aims of the study were to investigate the occurrence of cardiovascular diseases (CVD), diabetes (DM) and obesity in schizophrenia and depression in three different geographical areas - Asia (Japan), Africa (Nigeria) and Western Europe (Switzerland, Germany and Denmark) - and to search for possible transcultural differences in these correlations, which would also reflect the differences between low-income areas in Africa (Nigeria) and high-income areas in Europe and Japan.

METHOD

Patients with International Classification of Diseases (ICD-10) F2 diseases (schizophrenia spectrum disorders) and F3 diseases (affective disorders) admitted to one Nigerian, one Japanese, two Swiss, two German and six Danish centres during 1 year were included. Physical diseases in accordance with ICD-10 were also registered. Psychiatric and physical comorbidity were calculated and standardized rate ratio incidences of background populations were our primary measures.

RESULTS

Incidence rate ratios were increased for both CVD, DM and overweight in both F2 and F3 in all cultures (Western Europe, Nigeria and Japan) within the same ranges (however, the Japanese results should be interpreted conservatively owing to the limited sample size). Overweight among the mentally ill were marked in Nigeria. A parallelism of the incidence of overweight, CVD and diabetes with the occurrence in background populations was seen and was most marked in overweight.

CONCLUSIONS

Overweight, CVD and DM were increased in schizophrenia spectrum disorders and affective disorders in all three cultures investigated (Western Europe, Nigeria and Japan). Lifestyle diseases were also seen in Nigeria and Japan. The results from this study indicate that cultural background might be seen as an important factor in dealing with lifestyle diseases among people with a severe mental illness, as it is in the general population.

Exploring the potential prognostic effect of various country-specific health service data on all-cause mortality using data from a large prospective study in schizophrenia

PURPOSE

To explore whether the presence of specific health services impact the time to death in schizophrenia.

METHODS

Cox's proportional hazard model was used to assess the effect of country-specific health care variables (total health care expenditure, public health care expenditure, number of hospital beds, number of physicians, and World Health Organization ranking) on time to death in schizophrenia patients from a large multinational study. Baseline patient characteristics (history of suicide attempts and monotherapy or polytherapy at the time of study entry) were also included in the model.

RESULTS

The number of physicians per 10,000 persons was the only health service variable associated with time to death. Each increase of one physician increased the hazard of dying by approximately 2% (95%CI, from 0.1 to 4.1%; p = 0.044) in Europe, whereas in Asia, it seemed to decrease the hazard of dying by approximately 3.6% (95%CI, from 9.9% decrease to 3% increase; p = 0.28). The effect of region as a function of the number of physicians indicated a turning point at 23 physicians per 10,000 persons: With fewer than 23 physicians per 10,000 persons, the risk of death was higher in Asia than that in Europe (hazard ratio > 1), whereas with more than 23 physicians per 10,000 persons, it was lower in Asia than that in Europe (hazard ratio < 1).

CONCLUSIONS

Some health services may have a significant prognostic effect on time to death in patients treated for schizophrenia, especially in Europe. The reasons for this need to be identified.

Self-perception of aging and acute medical events in chronically institutionalized middle-aged and older persons with schizophrenia

OBJECTIVES

To examine the relationship between self-perceptions of aging and acute medical events in chronically institutionalized middle-aged and older persons with schizophrenia.

METHODS

Participants were 83 persons with schizophrenia (30% women; mean age = 58.48, SD = 8.14) residing in a long-stay care home, who were without organic mental disorders, mental retardation, serious audiovisual impairment, and serious cognitive and physical impairment. They received assessments in body mass index, functional health, and global mental status, and responded to measures of self-perception of aging at baseline. Acute events that required medical attention were recorded for the next 3 months.

RESULTS

8% of the participants had acute medical events. Bivariate analysis suggested that number of comorbid medical conditions, mobility, Mini-Mental State Examination, and negative self-perception of aging were predictive of acute medical events. However, multivariate analysis (logistic regression) showed that only mobility (OR = 0.78, p = 0.04) and negative self-perception of aging (OR = 3.38, p = 0.02) had independent effects on acute medical events, with the latter being the stronger predictor. Positive aging self-perception, body mass index, and smoking were unrelated to medical events.

CONCLUSIONS

Physical vulnerabilities may not be sufficient to explain the development of acute medical events in late-life schizophrenia. How individuals perceive their aging process, which is expected to regulate health behavior and help-seeking, may be an even more important factor. Further research should investigate whether such self-perceptions, which are probably rooted in stereotypes about aging socialized early in life, are modifiable in this population.

Changes in mortality after first psychiatric admission: a 20-year prospective longitudinal clinical study

OBJECTIVE

To examine changes in the mortality of patients admitted to a Norwegian psychiatric hospital from 1985 to 2003: this period saw profound changes in structure and organization of the mental healthcare system.

METHOD

A 20-year prospective longitudinal, record linkage study of all patients admitted to a psychiatric hospital with sector responsibility from 1985 to 2003.

RESULTS

Excess mortality was found for the patient group. Overall standardized mortality ratio (SMR) (95% confidence interval, CI) was 2.85 (2.53-3.07)/2.15 (1.94-2.41) for male/female patients. One third of the patients who died in the study period died within 2 years after first admission, and 45% of the deaths happened within 2 years after last discharge. The median age at death decreased in the study period for patients who were younger than 65 years at their first admission. The median difference of lost years of life for the patients younger than 65 years at first admittance was 26.95/23.96 years for male/female patients. SMR increased for the youngest cohorts during the study period over time. From 1985 to 2003, SMR increased dramatically for both genders.

CONCLUSION

Patients admitted to a Norwegian psychiatric hospital for their first stay during 1985-2003 suffered increased excess mortality, whereas mortality in the general population decreased. The mortality was highest in the first 2 years after admission. Despite profound changes in the mental healthcare system, the mortality gap increased in the study period and was highest in the youngest birth cohorts.

Psychiatric disorders in ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

Does deinstitutionalization increase suicide?

OBJECTIVES

(1) To test whether public psychiatric bed reduction may increase suicide rates; (2) to investigate whether the supply of private hospital psychiatric beds-separately for not-for-profit and for-profit-can substitute for public bed reduction without increasing suicides; and (3) to examine whether the level of community mental health resources moderates the relationship between public bed reduction and suicide rates.

METHODS

We examined state-level variation in suicide rates in relation to psychiatric beds and community mental health spending in the United States for the years 1982-1998. We categorize psychiatric beds separately for public, not-for-profit, and for-profit hospitals.

PRINCIPAL FINDINGS

Reduced public psychiatric bed supply was found to increase suicide rates. We found no evidence that not-for-profit or for-profit bed supply compensates for public bed reductions. However, greater community mental health spending buffers the adverse effect of public bed reductions on suicide. We estimate that in 2008, an additional decline in public psychiatric hospital beds would raise suicide rates for almost all states.

CONCLUSIONS

Downsizing of public inpatient mental health services may increase suicide rates. Nevertheless, an increase in community mental health funding may be promising.

Mortality of Finnish acute psychiatric hospital patients

OBJECTIVE

The mortality of psychiatric patients is higher than that of the general population. Earlier studies have typically focused on specific diagnostic categories or causes of death. The aim of this study was to assess the overall mortality in acute psychiatric hospital patients covering all diagnostic groups, with special emphasis on substance abuse.

METHODS

The sample consisted of all 18-64-year old patients (n = 3,835) treated or evaluated in the acute wards of the Department of Psychiatry at Tampere University Hospital between the years 1999 and 2003, who were followed-up until the end of the year 2005. We assessed the various causes of death according to background variables in bivariate and multivariate analyses and calculated the standardized mortality ratios (SMRs).

RESULTS

During the study period 379 subjects died (9.9% of the sample). Mortality among men was almost twice as high as among women. Of all deaths, 45.6% were considered to be alcohol or drug related. SMR covering all subjects was 6.55. The SMRs for unnatural causes were higher than those for natural causes. The highest SMRs for unnatural causes of death were found in patients with mood disorders and the highest SMRs for natural causes of death in patients with schizophrenia spectrum disorders. Use of coercive measures was associated with increased mortality.

CONCLUSION

Mortality among Finnish psychiatric acute hospital patients is considerably higher than in general population. Excessive alcohol consumption plays a major role in causing excess deaths that could be potentially avoided.

Metformin for metabolic dysregulation in schizophrenic patients treated with olanzapine

The second generation antipsychotic drugs, such as risperidone, olanzapine, and quetiapine, are effective in treating patients with schizophrenia and have been considered as the first line therapy. Recently, increasing attention has been drawn to the potential diabetogenic effect of these novel antipsychotics. The goal of this study was to evaluate the effect of metformin treatment on the olanzapine-induced metabolic disturbance in schizophrenic patients. Twenty-four schizophrenic subjects who had received olanzapine treatment at least 3 months were assigned to the therapy with metformin 1500 mg/day for 8 weeks. The metabolic parameters were quantitatively assessed at baseline, weeks 2, 4, and 8 by using the intravenous glucose tolerance test. After an 8-week treatment with metformin, the body weight, fasting levels of glucose, triglyceride, and insulin, insulin secretion, and insulin resistance significantly decreased. Half of study subjects with metabolic syndrome obtained improvement after the metformin trial. Subjects' psychopathological condition remained unchanged during the study period. The olanzapine-induced metabolic disturbance could be reversed after 8-week metformin treatment. Based on the results of this study, we hypothesize that metformin could modulate the effect of olanzapine-induced metabolic disturbance.

Mortality of geriatric and younger patients with schizophrenia in the community

Little is known about the differences in mortality among non-institutionalized geriatric and younger patients with schizophrenia. In this study long-term mortality and suicidal behavior of all the geriatric (age > or = 65 years), middle-age (age 41-64 years), and young (age 15-40 years) subjects with schizophrenia living in a Chinese rural community were compared. A 10 year follow-up investigation among a 1994 cohort (n = 510) of patients with schizophrenia was conducted in Xinjin County, Chengdu, China. Compared with young subjects, geriatric subjects with schizophrenia were more likely to be female, have more previous physical illness, never accepted treatment, and practice religious (p < or = 0.01). There were no significant differences of suicide attempts among the three groups. Young subjects had a higher rate of suicide (1,033.8 per 100,000 person-years), and geriatric subjects had a higher rate of deaths due to other causes (accident and natural causes) (4,314.2 per 100,000 person-years). Standardized mortality ratios for both suicide and deaths due to other causes were highest in young subjects and the lowest in geriatric subjects. Patients with schizophrenia in all age groups had a marked increase in mortality and suicide. Specific intervention strategies for decreasing mortality and suicide should be developed for patients with schizophrenia in different age groups.

Mortality in people with schizophrenia in rural China: 10-year cohort study

BACKGROUND

Long-term mortality and the risk factors for premature death among patients with schizophrenia living in rural communities are unknown.

AIMS

To explore the 10-year mortality and its risk factors among patients with schizophrenia.

METHOD

We used data from a 10-year prospective follow-up study (1994-2004) of mortality among people with schizophrenia, and death registration data for Xinjin County, Chengdu, China.

RESULTS

The mortality rate was 2228 per 100,000 person-years during follow-up. Both all-cause mortality and suicide rates were significantly greater in male than in female patients. Age at illness onset (>45 years), duration of illness (> or =10 years), age greater than 50 years, physical illness, in ability to work, male gender, and never having received treatment were identified as independent predictors of increased mortality.

CONCLUSIONS

Higher mortality rates in male patients may contribute to the higher prevalence of schizophrenia in women compared with men in China. The findings of risk factors for mortality should be taken into account when developing interventions to improve outcomes among people with schizophrenia.

Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline

Persons diagnosed with schizophrenia have higher morbidity and mortality rates from cardiovascular disease, yet often have limited access to appropriate primary care screening or treatment. Metabolic disorders such as diabetes, hyperlipidemia and hypertension are highly prevalent in populations with schizophrenia, exceeding 50% in some studies; however, there have been few published studies on treatment rates among schizophrenia patients screened for these disorders.

METHODS

Using the baseline data from subjects (N=1460) recruited into the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study, we examined the point prevalence of diabetes, hyperlipidemia and hypertension treatment at the time of enrollment for the entire cohort and those with fasting laboratory values obtained 8 or more hours since last meal.

RESULTS

Rates of non-treatment ranged from 30.2% for diabetes, to 62.4% for hypertension, and 88.0% for dyslipidemia. Nonwhite men were more likely to be treated for DM and dyslipidemia than nonwhite women.

CONCLUSIONS

These data indicate the high likelihood that metabolic disorders are untreated in patients with schizophrenia, with particularly high rates of non-treatment for hypertension and dyslipidemia. Nonwhite women may be especially vulnerable to undertreatment of dyslipidemia and diabetes compared to nonwhite men. The findings here support the need for increased attention to basic monitoring and treatment of cardiovascular risk factors in this vulnerable and often underserved psychiatric population.

Medical comorbidity in women and men with bipolar disorders: a population-based controlled study

OBJECTIVE

Rarely has validated information on chronic medical comorbidity been presented for persons with bipolar disorder. To deliver appropriate health services, it is important to understand the prevalence of chronic medical conditions in this population. This study examines chronic medical comorbidity using validated methodology in persons with bipolar disorder.

METHODS

This is a retrospective study of a 100% sample of administrative claims (1996-2001) from Wellmark Blue Cross Blue Shield. Three thousand five hundred fifty-seven subjects had bipolar I disorder and did not have claims for schizophrenia or schizoaffective disorder. Controls had no documented claims for psychiatric conditions. Using validated methodology, inpatient and outpatient claims were used to determine prevalence of 44 chronic medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental healthcare utilization.

RESULTS

Persons with bipolar disorder were young (mean age, 38.8 years) and significantly more likely to have medical comorbidity, including three or more chronic conditions (41% versus 12%, p < .001) compared with controls. Elevated ORs were found for conditions spanning all organ systems. Hyperlipidemia, lymphoma, and metastatic cancer were the only conditions less likely to occur in persons with bipolar disorder.

CONCLUSION

Bipolar disorders are associated with substantial chronic medical burden. Familiarity with conditions affecting this population may assist in programs aimed at providing medical care for the chronically mentally ill.

Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III

One important risk factor for cardiovascular disease is the metabolic syndrome (MS), yet limited data exist on its prevalence in US patients with schizophrenia.

METHODS

Using baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial, assessment of MS prevalence was performed based on National Cholesterol Education Program (NCEP) criteria, and also using a fasting glucose threshold of 100 mg/dl (AHA). Subjects with sufficient anthropometric data, data on use of antihypertensives, hypoglycemic medications or insulin, and fasting glucose and lipid values >8 h from last meal were included in the analysis. Comparative analyses were performed using a randomly selected sample from NHANES III matched 1:1 on the basis of age, gender and race/ethnicity.

RESULTS

Of 1460 CATIE baseline subjects, 689 met analysis criteria. MS prevalence was 40.9% and 42.7%, respectively using the NCEP and AHA derived criteria. In females it was 51.6% and 54.2% using the NCEP and AHA criteria, compared to 36.0% (p = .0002) and 36.6% (p = .0003), respectively for males. 73.4% of all females (including nonfasting subjects) met the waist circumference criterion compared to 36.6% of males. In a logistic regression model with age, race and ethnicity as covariates, CATIE males were 138% more likely to have MS than the NHANES matched sample, and CATIE females 251% more likely than their NHANES counterparts. Even when controlling for differences in body mass index, CATIE males were still 85% more likely to have MS than the NHANES male sample, and CATIE females 137% more likely to have MS than females in NHANES.

CONCLUSIONS

The metabolic syndrome is highly prevalent in US schizophrenia patients and represents an enormous source of cardiovascular risk, especially for women. Clinical attention must be given to monitoring for this syndrome, and minimizing metabolic risks associated with antipsychotic treatment.

The Clinical Antipsychotic Trials Of Intervention Effectiveness (CATIE) Schizophrenia Trial: clinical comparison of subgroups with and without the metabolic syndrome

The metabolic syndrome (MS) is highly prevalent among patients with schizophrenia (current estimates 35-40%), yet no data exist on the correlation of this diagnosis with illness severity, neurocognitive or quality of life measures in this population.

METHODS

Using baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial, assignment of MS status was performed using an updated definition derived from the National Cholesterol Education Program (NCEP) criteria. Those with and without MS were compared on the basis of primary and secondary variables of interest from baseline data encompassing psychiatric, neurocognitive and quality of life measures.

RESULTS

Of 1460 subjects enrolled at baseline, MS status could be reliably assigned for 1231 subjects, with a prevalence of 35.8% using the NCEP derived criteria. After adjustment for age, gender, race, ethnicity and site variance, those with MS rated themselves significantly lower on physical health by SF-12 (p < .001), and scored higher on somatic preoccupation (PANSS item G1) (p = .03). There were no significant differences between the two cohorts on measures of symptom severity, depression, quality of life, neurocognition, or self-rated mental health. Neither years of antipsychotic exposure nor alcohol usage were significant predictors of MS status when adjusted for age, gender, race, and ethnicity.

CONCLUSIONS

The metabolic syndrome is highly prevalent in this large cohort of schizophrenia patients and is strongly associated with a poor self-rating of physical health and increased somatic preoccupation. These results underscore the need for mental health practitioners to take an active role in the health monitoring of patients with schizophrenia to minimize the impact of medical comorbidity on long-term mortality and on daily functioning. Outcomes data from CATIE will provide important information on the metabolic and clinical impact of antipsychotic treatment for those subjects with MS and other medical comorbidities.

Cardiovascular disease in relation to weight in deceased persons with schizophrenia

This study evaluated body mass index, body surface area, subcutaneous fat tissue, and coronary atherosclerosis by autopsy reports for people with schizophrenia who were deceased to evaluate the presence of cardiac atherosclerosis and its association with body weight. Included in the study were autopsy reports for 134 people with schizophrenia and 134 matched normal subjects who had died between January 1990 and December 2000 and whose family had donated brain tissue to Maryland Brain Collection. Cause of death due to cardiovascular disease was observed for 45.7% of people with schizophrenia and 42.3% of the control group (P = NS). Body weight, body mass index, body surface area, and subcutaneous fat were not significantly different between the 2 groups; however, a larger proportion of the schizophrenia group had high (33.3%) and low (20.9%) percentile body weight compared with controls (27.7% vs 10.0%). People with schizophrenia who were underweight had higher rates of cardiac death than the controls (37.7% vs 13%) (chi(2) = 5.79, P = .01); however, no difference was noted in the number of coronary arteries occluded. Twenty-three (48.9%) of 47 of the controls with abnormally high subcutaneous fat showed cardiac atherosclerosis, whereas only 15 (33.3%) of 45 of the schizophrenia group with abnormally high subcutaneous fat had atherosclerosis (P = NS). Overall, the percentage of deaths due to cardiovascular disease was not higher in people with schizophrenia; however, in normal controls, cardiovascular disease appears to be related more to weight than in people with schizophrenia. This may be related to intrinsic metabolic differences associated with schizophrenia, lifestyle differences, or effects of antipsychotic medications. Nonetheless, our study suggests that efforts for the prevention of coronary atherosclerosis in schizophrenia patients should go beyond weight control to target multiple risk factors such as smoking, dyslipidemia, and cardiac side effect of antipsychotic medications.

Older people with chronic schizophrenia

Older people with chronic schizophrenia are a numerically small but important group with complex clinical and service needs. Along with a reduction in positive schizophrenic symptoms with increasing age, a majority suffer from negative symptoms, cognitive deficits, depression, side effects due to long-term use of antipsychotics and co-morbid medical problems. They may have social disabilities making them vulnerable to poverty, isolation and poor quality of life. Evidence suggests that judicious use of antipsychotics combined with psychotherapy and psychosocial interventions are effective. There are shortcomings in the standard of both hospital and community care, and the cost implications of providing adequate services are high.

Suicidal risk during treatment with clozapine: a meta-analysis

OBJECTIVE

Suicide remains a major cause of premature mortality among patients with schizophrenia. Evidence of reduced suicidal risk with available psychiatric treatments is limited, but emerging data suggest such an effect of clozapine in chronically psychotic patients, leading us to compile the reported evidence.

METHOD

We searched for published studies with contrasting rates of suicides or attempts by psychotic patients treated with clozapine vs. other agents.

RESULTS

Among six such studies, random-effects meta-analysis indicated a substantially lower overall risk of suicidal behaviors with clozapine vs. other treatments (risk-ratio 3.3; 95% confidence interval [CI] 1.7-6.3; p<0.0001). For completed suicides, the risk ratio (RR) was 2.9 ([CI 1.5-5.7]; p=0.002).

CONCLUSION

Long-term treatment with clozapine was associated with three-fold overall reduction of risk of suicidal behaviors. However, available findings are quantitatively inconsistent, well-designed studies remain rare, and the only randomized trial did not find reduced risk of completed suicide. Additional randomized comparisons among modern treatments for psychotic disorders are required to clarify their impact on mortality.

Occurrence of cancer among people with mental health claims in an insured population

OBJECTIVE

The objective of this research is to determine whether people with mental disorders are at increased risk for the subsequent development of malignancies compared with people without mental disorders.

METHODS

This is a retrospective cohort study of administrative claims data. The study population included 722,139 adults who filed at least one medical claim from 1989 to 1993. The mental disorder cohort included people with a) one psychiatric hospitalization, b) one outpatient psychiatrist visit, or c) two outpatient mental health claims occurring at least 6 months before a cancer claim. The controls were subjects filing claims for medical services who had no mental health visits. We calculated age-stratified odds ratios (ORs) for development of malignancy.

RESULTS

People with mental disorders were no more or less likely to develop a malignancy than those without after adjusting for age (women: OR, 1.03; 95% confidence interval [CI], 0.95-1.12; men: OR, 1.10; 95% CI, 0.97-1.24). People with mental disorders, however, developed cancer at younger ages and had increased odds of primary central nervous system tumors (women: OR, 2.12; 95% CI, 1.40-3.21; men: OR, 2.09; 95% CI, 1.22-3.59) and respiratory system cancers (women: OR, 1.57; 95% CI, 1.13-2.19; men: OR, 1.52; 95% CI, 1.09-2.12).

CONCLUSIONS

Insured people with mental disorder claims had an increased risk of certain malignancies and developed malignancies at younger ages. The increased odds of respiratory tumors are likely secondary to increased rates of smoking among people with mental disorders and support use of smoking cessation interventions in this population. The increased odds for brain tumors may reflect only the early presence of mental symptoms, or a true association between the two conditions. Further study of these findings is mandated.

Externally caused deaths for adults with substance use and mental disorders

For decades, there have been reports of shorter life expectancy among those with mental illness, especially those with more serious psychiatric disorders. The purpose of this study was to compare the risk of mortality among Medicaid beneficiaries, aged 18-64 years, treated for mental illness to a comparable group who were not mentally ill and to the general population. The data used were from the Massachusetts Division of Medical Assistance and records of deaths from the Department of Public Health in Massachusetts. Individuals treated for both psychiatric illness and substance use disorders (dual diagnoses) were compared separately from those whose treatment was only for a psychiatric disorder. For all Medicaid beneficiaries, the most common causes of death were attributed to heart disease and cancer. When compared to the general population, adjusted odds ratios estimated death by injury to be twice as likely among the mentally ill when compared to the general population. Medicaid beneficiaries with dual diagnoses are 6-8 times more likely to die of injury, primarily poisoning, than their counterparts treated for medical conditions only.

Clinical characteristics and length of hospital stay among older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia

Although many older adults with serious psychiatric illnesses share common concerns, such as medical comorbidity, personal loss, greater propensity for adverse medication effects, and greater dependence on others for basic needs such as transportation, individualized treatment needs must be differentiated by underlying psychiatric disorders. This retrospective study evaluated clinical characteristics and resource use among 137 older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia who were discharged from an urban, academic medical center's inpatient geropsychiatric unit. The authors found women to be significantly overrepresented among individuals with schizophrenia or schizoaffective disorder compared to those with bipolar disorder, depression, and dementia (P=.034). Among those with bipolar disorder, anticonvulsant medications were predominantly used as mood stabilizers, with only the rare use of lithium. Individuals with schizophrenia or schizoaffective disorder were the youngest group of patients; individuals with dementia were the oldest group (P<.001). This shows significant differences in clinical characteristics among hospitalized older adults with serious mental illnesses. Additional studies are needed on outcomes of serious chronic psychiatric illnesses in later life to optimize care environments for older adult psychiatric patients.

The association between schizophrenia and cigarette smoking: a review of the literature and implications for mental health nursing practice

Despite a fall in smoking activity among the general population, individuals with schizophrenia continue to smoke at alarming rates and suffer poor health as a consequence. It would appear that limited and conflicting knowledge, outdated perceptions, and ineffective interventions have hindered efforts to promote healthy behaviours among this group. This paper reviews the literature on the association between nicotine dependence and schizophrenia and explores explanations for the phenomenon. Complex psychopathological, biochemical, and neuropharmacological interactions between smoking and schizophrenia are revealed. The interface of schizophrenia and smoking behaviour, particularly among those hospitalized in mental health facilities, and rationales for the management of this manifestation are examined. In addition, inferences regarding the role of mental health nurses in the care of this population are reached, and implications for nursing practice are discussed.

Detection and management of comorbidity in patients with schizophrenia

Approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition, worsening prognosis and contributing to the high rate of morbidity and mortality. Depression is associated with suicide, the leading cause of premature death in patients with schizophrenia; obsessive-compulsive symptoms may worsen prognosis; alcohol and substance use disorders are associated with a poor outcome; and comorbid medical conditions, including cardiac and pulmonary disease, infectious diseases, diabetes, hyperlipidemia, hypogonadism, and osteoporosis, are often underrecognized and undertreated. The new generation of antipsychotic medications has improved the potential outcome of patients with schizophrenia. Providing optimal treatment for patients and fully realizing the potential of these new agents require focused attention on detection, recognition, and treatment of comorbid psychiatric and medical conditions in patients with schizophrenia.

Prospective analysis of premature mortality in schizophrenia in relation to health service engagement: a 7.5-year study within an epidemiologically complete, homogeneous population in rural Ireland

While premature death in schizophrenia is well recognised, mortality risk has received little longitudinal study in relation to population representativeness and patient engagement with health services. Within a rural Irish catchment area of socioeconomic, ethnic and geographical homogeneity and low residential mobility, an epidemiologically complete population of 72 patients with schizophrenia was followed up over 7.5 years in order to quantify mortality prospectively. Information was obtained in relation to 99% of the cohort, with 94% of those surviving retained in engagement with psychiatric care. There were 25 deaths (35% of cohort). A relative risk of 2.06 (95% CI, 1.40-2.80; P < 0.001) among this epidemiologically complete population may constitute an estimate of risk for mortality inherent to schizophrenia when disengagement from health services, residential mobility and socioeconomic, ethnic and geographical diversity are minimised. On long-term prospective evaluation, risk for death in schizophrenia was doubled on a background of enduring engagement in psychiatric care with increasing provision of community-based services and introduction of second-generation antipsychotics.

Characteristics of primary care visits for individuals with severe mental illness in a national sample

Individuals with severe mental illness (SMI) are at risk for inadequate general medical and preventive care, but little is known about their visits for primary care. We performed a cross-sectional analysis of primary care physician visits from the National Ambulatory Medical Care Survey (NAMCS) 1993-1998 and compared visit characteristics for patients with and without SMI. SMI was defined from ICD-9 diagnoses and medications. Primary care visits for patients with SMI were more likely to be return visits, were longer, and were more likely to have scheduled follow-up than for patients without SMI. Obesity, diabetes, and smoking were reported approximately twice as frequently in visits for patients with SMI compared to patients without SMI. The percent of visits with preventive counseling and counseling targeted at chronic medical conditions was similar for both groups. Likely appropriate to their complex needs, patients with SMI using primary care tend to have more return visits, longer time with the physician and are more often scheduled for follow-up care; their preventive counseling appears similar to non-SMI visits.

Gender related differences in clinical characteristics and hospital based resource utilization among older adults with schizophrenia

OBJECTIVE

This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period.

METHODS

This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use.

RESULTS

There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication.

CONCLUSIONS

In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders.

Coping with schizophrenia: patterns in later adulthood

By exploring the subjective experience of older people, this study investigated whether the coping framework developed with younger adults with schizophrenia could be applied to people with schizophrenia over the age of 50 years. Fifteen participants diagnosed with schizophrenia, over the age of 50, were recruited from clubhouses and given a semi-structured interview to identify what, if any, coping strategies were used to manage persistent symptoms. The results indicated that the coping strategies used by this older sample were similar to those reported by earlier studies with younger populations. However, it was reported that the efficacy of the coping strategies had increased as the participants had grown older and accepted their illness. Older adults with schizophrenia are capable of employing strategies to manage their illness and should be considered an important source of knowledge for younger individuals who struggle with the illness and for mental health professionals who work with the chronically mentally ill.

Recovery from psychotic illness: a 15- and 25-year international follow-up study

BACKGROUND

Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia.

AIMS

To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables.

METHODS

Historic prospective study. Standardised assessments of course and outcome.

RESULTS

About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery.

CONCLUSIONS

A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Reversal of pathologic cardiac parameters after transition from clozapine to olanzapine treatment: a case report

Antipsychotic medications have been associated with significant cardiovascular adverse effects and instances of sudden cardiac death. Recently, we started to evaluate cardiac parameters in medicated patients with schizophrenia using power spectrum analysis of heart rate variability. We present a case of a patient with long-standing schizophrenia who was treated with clozapine. His electrocardiogram revealed minor abnormalities, including a prolonged QT interval. Power spectrum analysis of heart rate variability demonstrated marked abnormalities in autonomic nervous system activity. Two years later, his treatment was switched to olanzapine. We reevaluated his cardiac parameters. Power spectrum analysis studies revealed that heart rate had significantly improved and that power spectrum cardiovascular parameters had returned to normal. Serial electrocardiograms revealed a minimally and asymptomatically prolonged QT interval. This case demonstrates the importance of screening electrocardiograms, even in healthy young patients. It also emphasizes how minor changes in electrocardiogram can be overlooked on standard electrocardiograms. Power spectrum analysis of heart rate variability is useful in this instance because it magnifies the trace and detects even minor disturbances. Care should be taken in prescribing antipsychotic drugs to patients who are prone to cardiovascular side effects, and alternatives to antipsychotics with prominent anticholinergic profile, in particular, should be sought.

Mortality and long-term course in schizophrenia with a poor 2-year course: a study in a developing country

BACKGROUND

The short-term course of schizophrenia is reported to be better in some developing country settings. The long-term course in such settings, however, has rarely been studied.

AIMS

To examine the long-term course and mortality of schizophrenia in patients with a poor 2-year course.

METHOD

The report is based on two incidence cohorts of first-contact patients in urban and rural Chandigarh, India, originally recruited for the World Health Organization Determinants of Outcome of Severe Mental Disorders study. Patients were assessed using standardised instruments at 2- and 15-year follow-ups.

RESULTS

Ninety-two per cent of the patients with a poor 2-year course had a poor long-term course and 47% died - a nine times higher mortality rate than among patients with other 2-year course types.

CONCLUSIONS

In this developing country setting, a poor 2-year course was strongly predictive of poor prognosis and high mortality, raising questions about the adequacy of care for such patients.

The impact of health status on work, symptoms, and functional outcomes in severe mental illness

This study evaluated the relationships between self-ratings of physical role functioning and general health, two components of the MOS SF-36, and a variety of demographic, quality of life, clinical, functional, and attitudinal variables in a cohort of adults living with severe and persistent mental illness (SPMI). We hypothesized that poorer self-perceptions of physical functioning and general health would be significantly related to more severe symptoms and poorer functioning and quality of life. Study subjects were 218 adults with SPMI enrolled in a randomized controlled trial comparing two vocational interventions for persons who were unemployed. Hierarchical regression analysis was used to determine whether psychiatric symptoms, poorer self-perceptions of role limitations due to physical health problems and overall general health independently contributed to more severe symptoms and poorer functioning and quality of life. Psychiatric symptoms were inversely related to size of social network and satisfaction with safety. Increased role limitations were associated with reduced medication compliance, general life satisfaction, and satisfaction with health, daily activities, and safety. Reduced general health was significantly associated with reduced work motivation, self-esteem, current inability to work, self-report of functioning, and almost all subjective life satisfaction domains. Within this group of people with severe mental illness, psychiatric symptoms were minimally associated with outcomes. Physical role limitations contributed more, and an integrated global measure of overall health perception was most important. If we are to help persons with severe mental illness maximize their quality of life and functioning, our clinical interventions should employ an approach that appreciates and recognizes the importance of the patients' experience of a holistic and integrated experience of health.

Schizophrenia and older adults. An overview: directions for research and policy

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

The association of medical comorbidity in schizophrenia with poor physical and mental health

This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

Schizophrenia and sudden death: a medical examiner case study

This study reviews the causes of sudden death of 66 schizophrenic patients who presented to the Office of the Chief Medical Examiner (OCME) for the State of Maryland over a 3-year period from 1994 through 1996. We identified an increased incidence of suicide compared with the general population of OCME cases. This observation is consistent with reports by other investigators. The majority of the deaths were the result of natural diseases, mostly atherosclerotic cardiovascular disease. Accidents, suicides, and 1 homicide were also present in this group.

Social environment and longevity in schizophrenia

OBJECTIVE

The role of social support as a predictor of long-term survival among patients with schizophrenia was examined.

METHODS

Social histories were abstracted from the medical records of a cohort of 133 deceased schizophrenic patients admitted for inpatient treatment between 1934 and 1944. Two independent raters assessed the quantity and quality of support available in each patient's social environment.

RESULTS

Cox regression analysis revealed that higher quantity of social support was significantly related to survival time (p<.05) after controlling for marital status and quality of support. The Cox model indicated that a 1-point increase in the support quantity rating was associated with a proportional 25% decrease in the hazard rate.

CONCLUSIONS

The present findings suggest that social environment, specifically the quantity of social support available to the patient, may impact longevity in psychiatric populations.