Decreased pain sensitivity among people with schizophrenia: a meta-analysis of experimental pain induction studies

Dysbiosis is associated with the behavioral phenotype observed in the triple-hit Wisket rat model of schizophrenia

Comorbidities between gastrointestinal diseases and psychiatric disorders have been widely reported, with the gut-brain axis implicated as a potential biological basis. Thus, dysbiosis may play an important role in the etiology of schizophrenia, which is barely detected. Triple-hit Wisket model rats exhibit various schizophrenia-like behavioral phenotypes. The present study aimed to compare the diversity and abundance of gut microbiota in Wisket model and control rats; furthermore, to correlate the microbial taxonomic profiles to indices of behavioral change. Tail-flick and Ambitus tests were used to assess acute heat pain sensitivity, and record exploration and locomotor activity along with motivation in young adult, control and Wisket model rats. Fecal microbiota composition was profiled by deep sequencing of bacterial 16S rRNA, and it was correlated to behavioral phenotype. Wisket rats exhibited significantly decreased pain sensitivity, lower locomotor activity and exploration, and impaired motivation compared with controls. No significant differences were observed in bacterial alpha diversity between the groups; however, clear differences in community structure were observed. Wisket rats showed decreases in several genera of Firmicutes and Saccharimonas, and increases in Bacteriodetes and Helicobacter phyla compared with controls. Correlation analysis revealed significant associations between the microbiota profile and the behavioral phenotype. This is the first demonstration that fecal microbiota composition is markedly altered in a triple-hit schizophrenia rat model, suggesting the contribution of the microbiota-gut-brain axis in the development of the schizophrenia-like behavioral phenotype. Thus targeting the gut microbiota may be a novel approach to treat such impairments.

Understanding the comorbidities among psychiatric disorders, chronic low-back pain, and spinal degenerative disease using observational and genetically informed analyses

Psychiatric disorders and symptoms are associated with differences in pain perception and sensitivity. These differences can have important implications in treating spinal degenerative disease (SDD) and chronic low-back pain (CLBP). Leveraging data from the UK Biobank (UKB) and the All of Us Research Program (AoU), we investigated the effects linking psychiatric disorders (alcohol use disorder, anxiety, attention deficit hyperactivity disorder, bipolar disorder, cannabis use disorder, depression, opioid use disorder, posttraumatic stress disorder, and schizophrenia) to SDD and CLBP. We applied multi-nominal regression models, polygenic risk scoring (PRS), and one-sample Mendelian randomization (MR) to triangulate the effects underlying the associations observed. We also performed gene ontology and drug-repurposing analyses to dissect the biology shared among mental illnesses, SDD, and CLBP. Comparing individuals affected only by SDD (UKB N=37,745, AoU N=3,477), those affected only by CLBP (UKB N=15,496, AoU N=23,325), and those affected by both conditions (UKB N=11,463, AoU N= 13,451) to controls (UKB N=337,362, AoU N= 117,162), observational and genetically informed analyses highlighted that the strongest effects across the three case groups were observed for alcohol use disorder, anxiety, depression, and posttraumatic stress disorder. Additionally, schizophrenia and its PRS appeared to have an inverse relationship with CLBP, SDD, and their comorbidity. One-sample MR highlighted a potential direct effect of internalizing disorders on the outcomes investigated that was particularly strong on SDD. Our drug-repurposing analyses identified histone deacetylase inhibitors as targeting molecular pathways shared among psychiatric disorders, SDD, and CLBP. In conclusion, these findings support that the comorbidity among psychiatric disorders, SDD, and CLBP is due to the contribution of direct effects and shared biology linking these health outcomes. These pleiotropic mechanisms together with sociocultural factors play a key role in shaping the SDD-CLBP comorbidity patterns observed across the psychopathology spectrum.

Comorbid health outcomes in patients with schizophrenia: an umbrella review of systematic reviews and meta-analyses

There is no comprehensive umbrella review exploring the connection between schizophrenia and various health outcomes. Therefore, we aimed to systematically review existing meta-analyses about schizophrenia-associated comorbid health outcomes and validate the evidence levels. We performed an umbrella review of meta-analyses of observational studies to explore comorbid health outcomes in individuals with schizophrenia. Searches were conducted across PubMed/MEDLINE, EMBASE, ClinicalKey, and Google Scholar up to September 5, 2023, targeting meta-analyses of observational studies related to comorbid health outcomes in individuals with schizophrenia. We applied AMSTAR2 for data extraction and quality assessment, adhering to PRISMA guidelines. Evidence credibility was evaluated and categorized by evidence quality. Our protocol was registered with PROSPERO (CRD42024498833). Risk and protective factors were analyzed and presented through equivalent odds ratios (eRR). In this umbrella review, we analyzed 9 meta-analyses, including 88 original articles, covering 21 comorbid health outcomes with over 66 million participants across 19 countries. Patients with schizophrenia showed significant associations with multiple health outcomes, including asthma (eRR, 1.71 [95% CI, 1.05-2.78], class and quality of evidence [CE] = non-significant), chronic obstructive pulmonary disease (1.73 [1.25-2.37], CE = weak), pneumonia (2.63 [1.11-6.23], CE = weak), breast cancer of female patients (1.31 [1.04-1.65], CE = weak), cardiovascular disease (1.53 [1.12-2.11], CE = weak), stroke (1.71 [1.30-2.25], CE = weak), congestive heart failure (1.81 [1.21-2.69], CE = weak), sexual dysfunction (2.30 [1.75-3.04], CE = weak), fracture (1.63 [1.10-2.40], CE = weak), dementia (2.29 [1.19-4.39], CE = weak), and psoriasis (1.83 [1.18-2.83] CE = weak). Our study underscores the imperative for an integrated treatment approach to schizophrenia, highlighting its broad impact across respiratory, cardiovascular, sexual, neurological, and dermatological health domains. Given the predominantly non-significant to weak evidence levels, further studies are needed to reinforce our understanding.

When Psychiatry Meets Cardiology: A Case Report on the Challenges of Diagnosing and Managing Cardiovascular Disease in Patients With Severe Mental Illness

Coronary artery aneurysms (CAA) are rare vascular abnormalities defined as focal dilations exceeding 1.5 times the diameter of an adjacent normal segment. Serious complications of CAAs include thrombosis, rupture, and myocardial infarction. Despite the risk of severe complications, patients with CAAs are often asymptomatic and diagnosed incidentally during imaging for unrelated conditions. The presence of a severe mental illness (SMI) poses additional challenges in dealing with patients with cardiovascular disease. We present the case of a 68-year-old woman who was admitted to the emergency department with hemoptysis, hypoxia, tachycardia, and hypertension in addition to being agitated and uncooperative. A computed tomography pulmonary angiography revealed several concerning findings, most notably an aneurysmal structure located inferior to the right pulmonary artery. Several challenges were faced in further investigating and managing the CAA discovery. These resulted from concerns surrounding the patient's ability to tolerate further investigations, the risk of poor compliance with medical management, and the limited capacity for invasive treatments. Following multi-disciplinary team discussions, conservative management was favored, and anticoagulation therapy was initiated. This case underscores the complexity of diagnosing and managing coronary artery aneurysms in patients with severe mental illness. The absence of standardized guidelines for CAAs further complicates management decisions, requiring a case-by-case approach. A holistic, patient-centered approach that integrates psychiatric, cardiovascular, and ethical considerations is essential in improving outcomes in this vulnerable population.

Examining Disparities in the Evaluation and Management of Cesarean Birth Pain Among Patients With and Without a Psychiatric Condition

Background Postoperative pain management is an important aspect of postpartum care following cesarean delivery (CD). This study aimed to determine whether differences exist in pain assessments and opioid administration after CD between patients with psychiatric illness and those without. Methodology This was a retrospective cohort study of 490 patients who underwent CD at an urban tertiary care center. Demographic and delivery data were collected by chart review. The primary outcomes were the number of pain assessments performed, average pain score, and amount of morphine milligram equivalents (MMEs) administered to patients with and without psychiatric illness. Results A total of 389 patients without a psychiatric diagnosis were compared to 101 patients with a psychiatric diagnosis. After adjusting for baseline characteristics in all models, psychiatric history had a significant effect on pain severity (β = 0.25; 95% confidence interval (CI) (0.00, 0.49); p = 0.046) and number of pain assessments (β = -2.41; 95% CI (-4.42, -0.41); p = 0.018), but not on MME administration (incidence rate ratio = 1.31; 95% CI (0.60, 2.92); p = 0.466). Patients with a psychiatric history reported more severe pain after CD and received fewer pain assessments. There was no significant difference in the amount of pain medication administered between groups. Conclusions In this study, patients with a psychiatric diagnosis received fewer pain assessments and reported more severe post-CD pain compared to those without. Despite this difference, both groups received similar amounts of pain medication, raising concern for bias and inadequate treatment of pain in patients with a psychiatric diagnosis.

Characterization of pain and somatization and its relationship with psychopathology in early onset psychosis

BACKGROUND

Early onset psychosis (EOP) frequently presents with a severe clinical phenotype and poor long-term prognosis. Clinical experience suggests that individuals with EOP have abnormal pain and somatosensory processing, yet relative to adult-onset psychosis, pain and somatic sensory processing in EOP have rarely been studied.

METHODS

The history of two characteristic patients is described to illustrate clinical presentations of pain in EOP patients. Furthermore, 31 patients with EOP were studied with self-reported questionnaires informing on pain severity, pain catastrophizing, central sensitization, and somatization. Structured clinical interviews were administered to confirm Diagnostic and Statistical Manual of Mental Disorders-5 EOP diagnosis and the patient's dimensions of psychopathology were measured by the Brief Psychiatric Rating Scale (BPRS).

RESULTS

Out of 31 EOP patients, 22 reported distressing pain, where higher pain severity corresponded with greater BPRS total and affectivity and resistance subscale scores. The degree of psychopathology was associated (N = 31; p < 0.05, FDR-corrected) with the magnitude of pain catastrophizing, central sensitization, and somatization. Multivariate analysis revealed relationships (N = 31; p < 0.05, FDR-corrected) between BPRS subscale (negative symptoms and activation) scores with somatization severity. The observed associations occurred independent of antipsychotic medication usage as quantified by chlorpromazine equivalent doses.

CONCLUSIONS

Pain and somatosensory symptoms could be a frequent cause of distress in patients with EOP and their severity associated with the degree of psychopathology. Future studies should determine if treating pain and somatic symptoms in EOP patients can lead to better control of psychosis as well as improve quality of life.

Therapeutic potential of transient receptor potential (TRP) channels in psychiatric disorders

Psychiatric disorders such as Bipolar disorder, Anxiety, Major depressive disorder, Schizophrenia, Attention-deficit/hyperactivity disorder, as well as neurological disorders such as Migraine, are linked by the evidence of altered calcium homeostasis. The disturbance of intra-cellular calcium homeostasis disrupts the activity of numerous ion channels including transient receptor potential (TRP) channels. TRP channel families comprise non-selective calcium-permeable channels that have been implicated in variety of physiological processes in the brain, as well as in the pathogenesis of psychiatric disorders. Through a comprehensive review of current research and experimentation, this investigation elucidates the role of TRP channels in psychiatric disorders. Furthermore, this review discusses about the exploration of epigenetics and TRP channels in psychiatric disorders.

Schizophrenia and Heart Health: Are Antipsychotics a Friend or Foe?

Schizophrenia is one of the most disabling of the psychiatric diseases. The Brief Psychiatric Rating Scale Extended (BRSE) is used to evaluate the severity of psychiatric symptoms. Long-acting injectable (LAI) antipsychotics are commonly used and are preferred over oral antipsychotic medications. A two-center-based cross-sectional study was performed on 130 patients diagnosed with schizophrenia or schizoaffective disorder based on the International Classification of Diseases 10 criteria. We studied the relation between the development of cardiovascular risk factors and the antipsychotic medication that was administered in these patients. Our study demonstrates strong links between several cardiovascular risk factors and the duration of psychosis; the duration of the LAI antipsychotic treatment; the duration between the onset of the disease and the start of LAI antipsychotic treatment; and the use of specific LAI antipsychotic medications.

Rhabdomyolysis during adjunctive treatment with cariprazine in a clozapine-resistant schizophrenia patient

We report the case of a 49-year-old male treatment-resistant schizophrenia patient, whose treatment with clozapine and sertraline was supplemented with cariprazine 1.5 mg/day while regularly presenting for electroconvulsive therapy. After 3 weeks of adjunctive treatment with cariprazine, blood tests revealed pronounced signs of rhabdomyolysis, including a creatine kinase serum level of 20 386 U/L and an AST serum level of 696 U/L. Clinically, the patient did not report somatic symptoms other than mild back pain. After discontinuation of cariprazine and normal saline infusion, the above-mentioned findings resolved rapidly. Although very rare, rhabdomyolysis can be a potentially dangerous side effect of cariprazine and clinicians should be aware of its possible occurrence.

Observational evidence linking psychotropic medicines to the dispensing of opioid agents in later life

BACKGROUND

The use of opioid medicines is common in developed countries, particularly among older adults and those with mental health disorders. It is unclear if the association between mental disorders and opioid medicines is causal, or is due to reverse causality or confounding.

METHODS

We used a 10% random sample of the Australian Pharmaceutical Benefits Scheme (years 2012-2022) to examine the cross-sectional, case-control and longitudinal association between the dispensing of antidepressants, anxiolytics, hypnotics, antipsychotics and lithium, and opioid medicines. We used logistic regression, structural equation models (SEM), and Cox regression to analyze the data. Analyses were adjusted for age (years), sex, and number of non-psychotropic medicines dispensed during the year.

RESULTS

The 2022 file contained 804 334 individuals aged 50 years or over (53.1% women), of whom 181 690 (22.6%) received an opioid medicine. The adjusted odds ratio of being dispensed opioid medicines was 1.44 (99% CI = 1.42-1.46) for antidepressants, 1.97 (99% CI = 1.92-2.03) for anxiolytics, 1.55 (99% CI = 1.51-1.60) for hypnotics, 1.32 (99% CI = 1.27-1.38) for antipsychotics, and 0.60 (99% CI = 0.53-0.69) for lithium. Similar associations were noticed when we compared participants who were or not dispensed opioid medicines in 2022 for exposure to psychotropic agents between 2012 and 2021. SEM confirmed that this association was not due to reverse causality. The dispensing of antidepressants was associated with increased adjusted hazard (HR) of subsequent dispensing of opioid medicines (HR = 1.29, 99% CI = 1.27-1.30). Similar associations were observed for anxiolytics, hypnotics and antipsychotics, but not lithium.

CONCLUSIONS

The dispensing of opioid medicines is higher among older individuals exposed to antidepressants, anxiolytics, hypnotics and antipsychotics than those who are not. These associations are not due to reverse causality or study design. Preventive strategies seeking to minimise the risk of inappropriate use of opioid medicines in later life should consider targeting this high-risk population.

Prescription opioid dispensing patterns among patients with schizophrenia or bipolar disorder

BACKGROUND

Patients with schizophrenia (SZ) or bipolar disorder (BD) may have increased risk of complications from prescribed opioids, including opioid-induced respiratory depression. We compared prescription opioid pain medication dispensing for patients with SZ or BD versus controls over 5 years to assess dispensing trends.

METHODS

This retrospective, observational study analysed US claims data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases for individuals aged 18-64 years with prevalent SZ or BD for years 2015-2019 compared with age- and sex-matched controls. Baseline characteristics, comorbidities, and medication use were assessed. Proportions of individuals dispensed prescription opioids chronically (ie, ≥70 days over a 90-day period or ≥ 6 prescriptions annually) or nonchronically (≥1 prescription, chronic definition not met) were assessed.

RESULTS

In 2019, the Commercial and Medicaid databases contained records for 4773 and 30,179 patients with SZ and 52,780 and 63,455 patients with BD, respectively. Patients with SZ or BD had a higher prevalence of comorbidities, including pain, versus controls in each analysis year. From 2015 to 2019, among commercially insured patients with SZ, chronic opioid-dispensing proportions decreased from 6.1% (controls: 2.7%) to 2.3% (controls: 1.2%) and, for patients with BD, from 11.4% (controls: 2.7%) to 6.4% (controls: 1.6%). Chronic opioid dispensing declined in Medicaid-covered patients with SZ from 15.0% (controls: 14.7%) to 6.7% (controls: 6.0%) and, for patients with BD, from 27.4% (controls: 12.0%) to 12.4% (controls: 4.7%). Among commercially insured patients with SZ, nonchronic opioid dispensing decreased from 15.5% (controls: 16.4%) to 10.7% (controls: 11.0%) and, for patients with BD, from 26.1% (controls: 17.5%) to 20.0% (controls: 12.2%). In Medicaid-covered patients with SZ, nonchronic opioid dispensing declined from 22.5% (controls: 24.4%) to 15.1% (controls: 12.7%) and, for patients with BD, from 32.3% (controls: 25.9%) to 24.6% (controls: 13.6%).

CONCLUSIONS

The proportions of individuals dispensed chronic or nonchronic opioid medications each year were similar between commercially and Medicaid-insured patients with SZ versus controls and were higher for patients with BD versus controls. From 2015 to 2019, the proportions of individuals who were dispensed prescription opioids chronically or nonchronically decreased for patients with SZ or BD and controls.

Prescriptions of psychotropic and somatic medications among patients with severe mental disorders and healthy controls in a naturalistic study

PURPOSE

Psychotropic and somatic medications are both used in treating severe mental disorders (SMDs). Realistic estimates of the prevalence of use across medication categories are needed. We obtained this in a clinical cohort of patients with SMD and healthy controls (HCs).

MATERIALS AND METHODS

Prescriptions filled at Norwegian pharmacies the year before and after admittance to the Thematically Organized Psychosis (TOP) study were examined in 1406 patients with SMD (mean age 32.5 years, 48.2% women) and 920 HC (34.1 years, 46.2% women). Using data from the Norwegian Prescription Database (NorPD), the number of users in different anatomical therapeutic chemical (ATC) categories was compared using logistic regression. Population estimates were used as reference data.

RESULTS

Use of antipsychotics (N05A), antiepileptics (N03A), antidepressants (N06A), anxiolytics (N05B), hypnotics and sedatives (N05C), anticholinergics (N04A), psychostimulants, attention deficit hyperactivity disorder and nootropic agents (N06B) and drugs for addiction disorders (N07B) was significantly more prevalent in patients with SMD than HC. Use of diabetes treatment (A10), antithrombotic drugs (B01), beta blockers (C07), lipid modifiers (C10), and thyroid and endocrine therapeutics (H03) was also more prevalent in patients with SMD, but with two exceptions somatic medication use was comparable to the general population. Among HC, there was low prevalence of use for most medication categories.

CONCLUSION

Patients were using psychiatric medications, but also several types of somatic medications, more often than HC. Still, somatic medication use was mostly not higher than in the general population. The results indicate that HC had low use of most medication types.

Pre-emptive ice pack cryotherapy for reducing pain caused by long-acting deltoid injectable antipsychotic treatment: A single-center open-label study

PURPOSE

This empirical study aims to investigate the efficacy of pre-emptive cryotherapy in reducing pain that is caused by the deltoid intramuscular (IM) injection of long-acting injectable (LAI) antipsychotics in clinical settings.

PATIENTS AND METHODS

This study included 29 outpatients receiving LAI antipsychotic treatment. The evaluations of pain during (1) the usual procedure (control), (2) pre-emptive use of ice pack cryotherapy (pre-cooling), and (3) pre-emptive use of a room-temperature ice pack (pre-touching) were conducted using a numerical rating scale (NRS) for comparison. All patients were administered with LAI antipsychotics via deltoid IM. Furthermore, the results of the Positive and Negative Symptom Scale (PANSS), clinical global impressions (CGI) scale, and Global Assessment of Functioning (GAF) scale that were administered during the control procedure were evaluated.

RESULTS

The median NRS pain scores during the IM injection of LAI antipsychotics were 4.0 (3.0-5.0), 2.0 (1.0-3.0), and 3.0 (2.5-6.0) for the control, pre-cooling, and pre-touching conditions, indicating a significant difference (p = 6.0 × 10-6). The NRS pain scores for the pre-cooling condition were significantly lower than those for the control and pre-touching conditions (p = 2.5 × 10-5 and 6.7 × 10-5, respectively). No significant correlation was observed between the NRS pain scores for the control condition and the PANSS, CGI scale, or GAF scale scores. Furthermore, no adverse events were recorded during the study period.

CONCLUSION

Pain during the deltoid IM injection of LAI antipsychotics was found to be reduced by pre-emptive skin cooling. To date, this is the first study to confirm the effectiveness of pre-emptive cryotherapy for relieving such pain in clinical situations.

Pain tolerance and threshold in suicide attempters: A systematic review and meta-analysis

It has been hypothesized that individuals less sensitive to pain could be at higher risk of suicide. However, data on pain sensitivity in suicide attempters (SA) obtained using experimental procedures are heterogeneous. The aim of this systematic review and meta-analysis was to investigate and compare pain tolerance and threshold in SA (patients with lifetime history of suicide attempt), non-attempters (psychiatric controls, PC), and healthy controls (HC). A random effects meta-analysis was used to estimate the standardized mean differences using data from 16 studies that compared physical pain tolerance and threshold in SA and PC or HC. Pain tolerance and threshold were not significantly different in SA and PC. However, pain tolerance, but not threshold, was higher in SA than HC. Our findings do not support the hypothesis of an altered pain perception related as a trait for suicidal vulnerability, but rather suggest altered pain perception related to psychiatric vulnerability.

Multimorbidity clusters among people with serious mental illness: a representative primary and secondary data linkage cohort study

BACKGROUND

People with serious mental illness (SMI) experience higher mortality partially attributable to higher long-term condition (LTC) prevalence. However, little is known about multiple LTCs (MLTCs) clustering in this population.

METHODS

People from South London with SMI and two or more existing LTCs aged 18+ at diagnosis were included using linked primary and mental healthcare records, 2012-2020. Latent class analysis (LCA) determined MLTC classes and multinominal logistic regression examined associations between demographic/clinical characteristics and latent class membership.

RESULTS

The sample included 1924 patients (mean (s.d.) age 48.2 (17.3) years). Five latent classes were identified: 'substance related' (24.9%), 'atopic' (24.2%), 'pure affective' (30.4%), 'cardiovascular' (14.1%), and 'complex multimorbidity' (6.4%). Patients had on average 7-9 LTCs in each cluster. Males were at increased odds of MLTCs in all four clusters, compared to the 'pure affective'. Compared to the largest cluster ('pure affective'), the 'substance related' and the 'atopic' clusters were younger [odds ratios (OR) per year increase 0.99 (95% CI 0.98-1.00) and 0.96 (0.95-0.97) respectively], and the 'cardiovascular' and 'complex multimorbidity' clusters were older (ORs 1.09 (1.07-1.10) and 1.16 (1.14-1.18) respectively). The 'substance related' cluster was more likely to be White, the 'cardiovascular' cluster more likely to be Black (compared to White; OR 1.75, 95% CI 1.10-2.79), and both more likely to have schizophrenia, compared to other clusters.

CONCLUSION

The current study identified five latent class MLTC clusters among patients with SMI. An integrated care model for treating MLTCs in this population is recommended to improve multimorbidity care.

Maternal immune activation alters placental histone-3 lysine-9 tri-methylation, offspring sensorimotor processing, and hypothalamic transposable element expression in a sex-specific manner

Animal models of maternal immune activation (MIA) are central to identifying the biological mechanisms that underly the association between prenatal infection and neuropsychiatric disorder susceptibility. Many studies, however, have limited their scope to protein coding genes and their role in mediating this inherent risk, while much less attention has been directed towards exploring the roles of the epigenome and transposable elements (TEs). In Experiment 1, we demonstrate the ability of MIA to alter the chromatin landscape of the placenta. We induced MIA by injecting 200 μg/kg (i.p.) of lipopolysaccharide (LPS) on gestational day 15 in Sprague-Dawley rats. We found a sex-specific rearrangement of heterochromatin 24-h after exposure to MIA, as evidenced by an increase in histone-3 lysine-9 trimethylation (H3K9me3). In Experiment 2, MIA was associated with long-term sensorimotor processing deficits as indicated by reduced prepulse inhibition (PPI) of the acoustic startle reflex in adult male and female offspring and an increased mechanical allodynia threshold in males. Analyses of gene expression within the hypothalamus-chosen for its involvement in the sex-specific pathogenesis of schizophrenia and the stress response-revealed significantly higher levels of the stress-sensitive genes Gr and Fkbp5. Deleterious TE expression is often a hallmark of neuropsychiatric disease and we found sex-specific increases in the expression of several TEs including IAP, B2 SINE, and LINE-1 ORF1. The data from this study warrant the future consideration of chromatin stability and TEs as part of the mechanism that drives MIA-associated changes in the brain and behavior.

Coronary Artery Disease in Patients with Severe Mental Illness

Severe mental illnesses (SMI), such as schizophrenia and bipolar disorder, are associated with a decrease in life expectancy of up to two decades compared with the general population, with cardiovascular disease as the leading cause of death. SMI is associated with increased cardiovascular risk profile and early onset of incident cardiovascular disease. Following an acute coronary syndrome, patients with SMI have a worse prognosis, but are less likely to receive invasive treatment. In this narrative review, the management of coronary artery disease in patients with SMI is discussed, and avenues for future research are highlighted.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Dysregulation of dopamine neurotransmission in the nucleus accumbens in immobilization-induced hypersensitivity

Cast immobilization causes sensory hypersensitivity, which is also a symptom of neuropathic pain and chronic pain. However, the mechanisms underlying immobilization-induced hypersensitivity remain unclear. The present study investigated the role of dopamine neurotransmission in the nucleus accumbens shell (NAcSh) of rats with cast immobilization-induced mechanical hypersensitivity using in vivo microdialysis. Cast immobilization of the hind limb decreased the paw withdrawal threshold (PWT). Mechanical stimulation of the cast-immobilized hind limb induced a decrease in dopamine in the NAcSh, and this decrease was associated with the upregulation of presynaptic D2-like receptors. A D2-like receptor antagonist infused into the NAcSh reversed the decrease in PWT in rats with cast immobilization, whereas a D2-like receptor agonist infused into the NAcSh induced a decrease in PWT in control rats. In addition, the expression of the D2 receptor (Drd2) mRNA in the NAcSh was increased by cast immobilization. Importantly, systemic administration of the D2-like receptor antagonist reversed the decrease in PWT in rats with cast immobilization. As dopamine levels regulated by presynaptic D2-like receptors did not correlate with the PWT, it is presumed that the D2-like receptor antagonist or agonist acts on postsynaptic D2-like receptors. These results suggest that immobilization-induced mechanical hypersensitivity is attributable to the upregulation of postsynaptic D2-like receptors in the NAc. Blockade of D2-like receptors in the NAcSh is a potential therapeutic strategy for immobilization-induced hypersensitivity.

Higher amoebic and metronidazole resistant forms of Blastocystis sp. seen in schizophrenic patients

Background

Blastocystis sp. is one of the most common colonisers of the intestinal tract that demonstrate strong interaction with accompanying gut bacteria. Previously, the protozoan isolated from individuals with irritable bowel syndrome (IBS) showed altered phenotypic features suggesting that it can be triggered to become pathogenic. Previous studies reported altered gut microbiota and high prevalence of Blastocystis sp. in schizophrenia patients. However, the phenotypic characteristics of Blastocystis sp. isolated from individuals with SZ have yet to be described.

Methods

In this study, faecal samples from 50 patients with severe schizophrenia (SZ) and 100 non-schizophrenic (NS) individuals were screened for Blastocystis sp. infection. Positive isolates were subjected to genotypic and phenotypic characterization.

Results

We found that 12 out of 50 (24%) SZ and 5 out of 100 (5%) NS individuals were detected Blastocystis sp. positive using both in vitro culture and PCR method with no significant association to age and gender. Out of the 15 sequenced isolates, ST3 was the most prevalent subtype (66.7%) followed by ST1 (20%) and ST6 (13.3%). The isolates from SZ individuals demonstrated significant slower growth rate (34.9 ± 15.6 h) and larger range of cell diameter (3.3–140 µm). We detected higher amoebic forms and metronidazole resistance among SZ isolates with variation in cell surface glycoprotein where 98% of cells from SZ showed consistent medium to high binding affinity (+ 2 to + 3) to Concavalin A staining compared to NS isolates that demonstrated only 76% high lectin (+ 3) binding affinity. Cysteine and serine protease levels were predominantly found among SZ isolates. We also demonstrate the presence of metalloprotease in Blastocystis sp. especially among NS isolates. Introduction of solubilised antigens from SZ isolates increased the cell proliferation of HCT116 cells by two fold when compared to NS isolates.

Conclusion

Our findings demonstrated Blastocystis sp. isolated from SZ individuals showed variation in phenotype specifically in morphology and drug resistance. The findings indicate that the gut environment (SZ and NS) and treatment of SZ could have influenced the phenotype of Blastocystis sp.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05418-0.

Pain management in people with severe mental illness: an agenda for progress

Supplemental Digital Content is Available in the Text.

Issues of cancer care in people with mental disorders as perceived by cancer care providers: A quantitative questionnaire survey

OBJECTIVES

To reduce cancer care disparities, this study aimed to clarify the difficulties in cancer care for people with mental disorders as perceived by cancer care providers.

METHODS

Cancer care providers at 17 designated cancer hospitals in Japan were surveyed using mail questionnaires. Respondents were asked to rate 29 items related to difficulties or insufficiencies in cancer care for patients with mental disorders on a five-point Likert scale. We analyzed the proportion of respondents who answered "difficult/insufficient" in each item. We also calculated the proportions of responders stratified according to the presence of psychiatric support systems within their hospitals.

RESULTS

A total of 388 (58.4%) cancer care providers responded. Among the issues related to "difficulties in diagnosing and treating cancer," support for decision-making, assessment of treatment adherence, and assessment of physical symptoms were perceived as most difficult (73.5%-81.5% of respondents). Among the issues related to 'difficulties or insufficiencies in collaboration among multidisciplinary health care providers,' the issue of advance consultation and sharing information with the patient's primary psychiatric care provider was perceived as most difficult (52.2%). Among the issues related to "insufficiencies of in-hospital and community medical systems," education to provide reasonable accommodation was perceived as most insufficient (47.4%). The perceived difficulties of over half of the issues varied significantly between hospitals depending on the level of psychiatric support systems.

CONCLUSIONS

This study clarified the difficulties of cancer care in patients with mental disorders as perceived by cancer care providers. Some issues may be resolved by psychiatric liaison teams.

Advantages and Limitations of Animal Schizophrenia Models

Mental illness modeling is still a major challenge for scientists. Animal models of schizophrenia are essential to gain a better understanding of the disease etiopathology and mechanism of action of currently used antipsychotic drugs and help in the search for new and more effective therapies. We can distinguish among pharmacological, genetic, and neurodevelopmental models offering various neuroanatomical disorders and a different spectrum of symptoms of schizophrenia. Modeling schizophrenia is based on inducing damage or changes in the activity of relevant regions in the rodent brain (mainly the prefrontal cortex and hippocampus). Such artificially induced dysfunctions approximately correspond to the lesions found in patients with schizophrenia. However, notably, animal models of mental illness have numerous limitations and never fully reflect the disease state observed in humans.

Childhood maltreatment and its role in the development of pain and psychopathology

Childhood maltreatment represents a form of trauma capable of altering fundamental neurobiological properties and negatively impacting neurodevelopmental processes. An outcome of childhood maltreatment is the emergence of psychopathology, which might become evident during childhood or adolescence, but might also project into adulthood. In this Review, we propose a biobehavioural framework in which childhood maltreatment and the associated aberrant neurobiological mechanisms and behavioural processes additionally lead to the onset of altered pain processing and, ultimately, the existence of pain syndromes. Considering that subpopulations of maltreated children show preserved function and minimal psychiatric or pain symptoms, compensatory mechanisms-perhaps instilled by robust psychosocial support systems-are also discussed. We present validated tools and experimental methods that could facilitate better comprehension of the interactions between childhood maltreatment, psychopathology, and pain. Such tools and approaches can in parallel be implemented to monitor abnormal pain-related processes and potentially guide early intervention strategies in cases of childhood maltreatment.

The neurobiology of childhood trauma, from early physical pain onwards: as relevant as ever in today's fractured world

Background: The situation in the world today, encompassing multiple armed conflicts, notably in Ukraine, the Coronavirus pandemic and the effects of climate change, increases the likelihood of childhood exposure to physical injury and pain. Other effects of these worldwide hardships include poverty, malnutrition and starvation, also bringing with them other forms of trauma, including emotional harm, neglect and deliberate maltreatment. Objective: To review the neurobiology of the systems in the developing brain that are most affected by physical and emotional trauma and neglect. Method: The review begins with those that mature first, such as the somatosensory system, progressing to structures that have a more protracted development, including those involved in cognition and emotional regulation. Explored next are developing stress response systems, especially the hypothalamic-pituitary-adrenal axis and its central regulator, corticotropin-releasing hormone. Also examined are reward and anti-reward systems and genetic versus environmental influences. The behavioural consequences of interpersonal childhood trauma, focusing on self-harm and suicide, are also surveyed briefly. Finally, pointers to effective treatment are proffered. Results: The low-threshold nature of circuitry in the developing brain and lack of inhibitory connections therein result in heightened excitability, making the consequences of both physical and emotional trauma more intense. Sensitive and critical periods in the development of structures such as the amygdala render the nervous system more vulnerable to insults occurring at those points, increasing the likelihood of psychiatric disorders, culminating in self-harm and even suicide. Conclusion: In view of the greater excitability of the developing nervous system, and its vulnerability to physical and psychological injuries, the review ends with an exhortation to consider the long-term consequences of childhood trauma, often underestimated or missed altogether when faced with adults suffering mental health problems.

Altered physical pain processing in different psychiatric conditions

Several reports indicate either increased or decreased pain sensitivity associated with psychiatric disorders. Chronic pain is highly prevalent in many of these conditions. We reviewed the literature regarding experimental pain sensitivity in patients with major depression, bipolar disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, panic disorder, obsessive-compulsive disorder and schizophrenia. Electronic searches were performed to identify studies comparing experimental pain in patients with these conditions and controls. Across 31 depression studies, reduced pain threshold was noted except for ischemic stimuli, where increased pain tolerance and elevated sensitivity to ischemic pain was observed. A more pervasive pattern of low pain sensitivity was found across 20 schizophrenia studies. The majority of PTSD studies (n = 20) showed no significant differences compared with controls. The limited number of bipolar disorder (n = 4) and anxiety (n = 9) studies precluded identification of clear trends. Wide data variability was observed. Awareness of psychiatric patients' pain perception abnormalities is needed for active screening and addressing physical comorbidities, in order to enhance quality of life, life expectancy and mental health.

Interoception abnormalities in schizophrenia: A review of preliminary evidence and an integration with Bayesian accounts of psychosis

Schizophrenia research has traditionally focused almost exclusively on how the brain interprets the outside world. However, our internal bodily milieu is also central to how we interpret the world and construct our reality: signals from within the body are critical for not only basic survival, but also a wide range of brain functions from basic perception, emotion, and motivation, to sense of self. In this article, we propose that interoception-the processing of bodily signals-may have implications for a wide range of clinical symptoms in schizophrenia and may thus provide key insights into illness mechanisms. We start with an overview of interoception pathways. Then we provide a review of direct and indirect findings in various interoceptive systems in schizophrenia and interpret these findings in the context of computational frameworks that model interoception as hierarchical Bayesian inference. Finally, we propose a conceptual model of how altered interoceptive inference may contribute to specific schizophrenia symptoms-negative symptoms in particular-and suggest directions for future research, including potential new avenues of treatment.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

Risk of COVID-19 diagnosis and death in patients with mental illness: a cohort study

AIMS

Patients with mental illness are vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection because of behavioural changes associated with cognitive deterioration, especially without their caregivers. While studies have reported that SARS-CoV-2 infection risk and severe clinical outcomes are high among patients with mental illness, there is a lack of quantitative research supporting this claim. This study investigates if SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related death are higher in patients with mental illness than among those without a mental disorder.

METHODS

A cohort study was conducted using the COVID-19 database of the National Health Insurance Service in South Korea. A total of 123 480 patients aged ⩾20 years who visited a hospital between 1 January 2020 and 30 May 2020 were analysed. Mental disorder diagnoses and types were determined based on 2019 medical records, and a multivariate logistic regression model was used to calculate the odds ratios (ORs) for SARS-CoV-2 infection and deaths.

RESULTS

The ORs for SARS-CoV-2 infection (OR 1.58; 95% CI 1.45-1.71) and COVID-19-related death (OR 2.18; 95% CI 1.57-3.04) were high among patients with mental illness. The OR of SARS-CoV-2 infection was higher among patients with severe mental illness (OR 2.60; 95% CI 2.21-3.06), dementia (OR 1.90; 95% CI 1.62-2.22) and substance use disorder (OR 4.98, 95% CI 3.60-6.88). The OR for COVID-19-related death was high among patients with severe mental illness (OR 3.53; 95% CI 1.82-6.83) and dementia (OR 2.12; 95% CI 1.39-3.22).

CONCLUSIONS

Patients with mental illness are at high risk for SARS-CoV-2 infection and COVID-19-related death. Behavioural changes associated with cognitive deterioration and long-term care facility residence increase SARS-CoV-2 infection risk, and severe medical conditions and delayed treatment increase the COVID-19-related mortality risk in patients with mental illness. Patients with mental illness are a priority target population for COVID-19 prevention and treatment, and it is important to plan prevention measures that address their needs.

Evaluation of acute and chronic nociception in subchronically administered MK-801-induced rat model of schizophrenia

Patients diagnosed with schizophrenia have been reported to exhibit atypically low pain sensitivity and to vary in their experience of chronic pain. To the best of our knowledge, there has yet to be an animal study that provides information concerning the relationship between models of schizophrenia and pain. In the present study, we investigated several distinct nociceptive behaviors in a translational rat model of schizophrenia (0. 5 mg/kg MK-801, twice a day for 7 days followed by a 7-day washout period). The presence of the expected cognitive deficit was confirmed with novel object recognition (NOR) paradigm prior to nociception testing. MK-801-treated rats with lack of novelty interest in NOR testing showed: hyposensitivity to thermal and mechanical stimuli; short-term hypoalgesia followed by augmented hyperalgesia in response to formalin-induced spontaneous nociception and increased thermal and mechanical hyperalgesia in the complete Freund's adjuvant (CFA) induced chronic pain model. In conclusion, MK-801 induced antinociception effects for thermal stimuli in rats that were consistent with the decreased pain sensitivity observed in schizophrenia patients. Additionally, the amplified biphasic response exhibited by the MK-801 group in the formalin-induced spontaneous nociception test affirms the suitability of the test as a model of acute to delayed pain transition.

Psychophysiological stress-reactivity in clinical and non-clinical voice-hearers

BACKGROUND

Psychosis is associated with dysregulation of psychophysiological stress-reactivity, including in subjective, autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) parameters.

AIMS

This study investigated whether dysregulated psychophysiological stress-reactivity is specifically associated with auditory verbal hallucinations (AVHs) or psychosis more generally by comparing voice-hearers with and without a need for care.

METHOD

Clinical (n = 20) and non-clinical voice-hearers (n = 23), as well as a healthy control group with no voices (n = 23), were compared on HPA and ANS responses, and subjective reactivity, to a psychophysiological stress paradigm, the socially evaluative cold pressor test.

RESULTS

Measures of HPA function in both clinical and non-clinical voice-hearers diverged from non-voice-hearing controls. Clinical participants showed a blunted peak response compared to both non-clinical groups (p = 0.02), whilst non-clinical voice-hearers showed, at trend-level, reduced cortisol levels during stress exposure compared to both clinical voice-hearers (p = 0.07) and healthy controls (p = 0.07), who unexpectedly did not differ from each other (p = 0.97). Clinical participants showed greater subjective stress levels than both non-clinical groups (p < 0.001), as well as greater anticipatory stress (p = 0.001) and less recovery. There were no differences between groups on parameters of the ANS (all p > 0.05).

CONCLUSIONS

Dysregulated psychophysiological stress-function is present in clinical voice-hearers, and partially discriminates them from non-clinical voice-hearers. Overall, the present findings identified specific potential psychophysiological markers of risk and resilience in auditory verbal hallucinations and need for care.

Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span

Importance

Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span.

Objective

To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population.

Design, Setting, and Participants

Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021.

Main Outcomes and Measures

For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity.

Results

The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up.

Conclusions and Relevance

In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

Medial Pelvic Migration of the Lag Screw after Intramedullary Nailing for Trochanteric Femoral Fracture

Internal fixation with intramedullary nails has gained popularity for the treatment of trochanteric femoral fractures, which are common injuries in older individuals. The most common complications are lag screws cut-out from the femoral head and femoral fracture at the distal tip of the nail. Herein, we report a rare complication of postoperative medial pelvic migration of the lag screw with no trauma. The patient was subsequently treated by lag screw removal via laparoscopy. This case suggests that optimal fracture reduction, adequate position of the lag screw, and careful attention to set screw insertion are important to prevent complications. Additionally, laparoscopic surgery might be able to remove the lag screw more safely than removal from the femoral side.

Clozapine-Induced Constipation: A Case Report and Review of Current Management Guidelines

Clozapine is a second-generation antipsychotic recommended after the failure of two or more antipsychotics for treatment-resistant schizophrenia. Clozapine proved to also decrease recurrent suicidal behaviors in schizophrenia spectrum disorders. Yet, physicians often use clozapine as a last resort despite its proven efficacy due to its side effect profile. A noted side effect of clozapine is agranulocytosis, which requires a weekly complete blood count with differentials. Clozapine's anticholinergic activity causes colonic hypomotility, leading to constipation, and only a few studies examined clozapine-induced constipation (CIC). Few of the reported complications of CIC include bowel obstruction or bowel perforation due to fecal impaction. Herein we document a case report of CIC and also conducted a review of published case reports examining the complexity and management of CIC. CIC is a critical condition if unresolved as it can lead to mortality. Future directions and guidelines should be developed for early diagnosis and treatment for CIC, which will provide reassurance and directions for both the physicians and patients.

Pain Sensitivity in Schizophrenia Spectrum Disorders: A Narrative Review of Recent Work

Many patients with schizophrenia seem relatively immune to physical pain while others complain of constant pain. This may result from disturbances or alterations of the sensory threshold for pain in populations with psychosis, a possibility for which there is some preliminary evidence. The inconsistency in pain perception may, in part, be explained by the treatments patients receive, but treatment-naïve patients also exhibit differences in response to pain. This suggests that decreased pain sensitivity may represent a specific psychosis endophenotype. Thus far, few experimental studies have investigated sensory thresholds, pain modalities, or other factors contributing to the perception or expression of physical pain in psychosis. A digital search for information on this topic was conducted in PubMed and Google Scholar. The result is a non-systematic, narrative review focusing on recent clinical and experimental findings of pain sensitivity in patients with psychosis. Importantly, physical and mental pain are closely connected constructs that may be difficult to differentiate. Our hope is that the review provides some clarity to the field in the specific context of schizophrenia.

Outpatient prescribing of opioids to adults diagnosed with mental disorders in the United States

BACKGROUND

Adults with mood and anxiety disorders have an increased likelihood of being prescribed opioids. The influence of other mental disorders, such as psychotic and attention disorders, on opioid prescribing patterns is less known.

METHODS

We studied a population-representative sample of 166,927 outpatient visits for adults with painful conditions from the 2002-2016 National Ambulatory Medical Care Survey and the 2002-2011 National Hospital Ambulatory Medical Care Survey. Logistic regression analyses examined the likelihood of opioid prescription among visits with specific mental disorder diagnoses (anxiety, attention, mood, psychotic, post-traumatic stress disorder (PTSD), opioid use, and non-opioid substance use), adjusted for covariates and weighted for the complex survey design. Secondary analyses stratified results by whether opioids were newly initiated or continued.

RESULTS

Opioids were prescribed at 16.8 % of visits. Mood, anxiety, and non-opioid substance use disorders were associated with higher likelihoods of opioid prescriptions, particularly for continued rather than first-time prescriptions. Psychotic disorders were strongly negatively associated with opioid prescriptions (adjusted odds ratio 0.44, 95 % CI 0.22-0.86). Diagnoses of PTSD and attention disorders were not associated with opioid prescribing.

CONCLUSIONS

Outpatient physicians are more likely to prescribe and refill opioids for adults with pain who present with mood, anxiety, and non-opioid substance use disorders, but not for those who present with PTSD or attention disorders. Patients with psychotic disorders and pain are markedly less likely to be prescribed opioids.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Influence of Substance Use on Side Effects of Olanzapine, Quetiapine, Risperidone, and Ziprasidone in Psychosis

BACKGROUND

Side effects restrict the optimal use of antipsychotics. Little is known about the influence of substance use on side effects. The aim of this study was to compare antipsychotic side effects in patients with psychosis with and without substance use, while also taking medication history and diagnosis into consideration.

METHODS

All patients (n = 226, mean age 34, females 33%) diagnosed with schizophrenia spectrum disorders (SSD; F20-F29) or other psychosis (F30-F32; F10-F19), were treated with olanzapine, quetiapine, risperidone or ziprasidone, and were assessed at baseline, 4-weeks, 14-weeks, and 27-weeks. The UKU-Side Effects Self-Rating Scale version was used to evaluate the side effect profiles, and the information on substance use was based on the Clinician Drug Use Scale.

RESULTS

At baseline, 30% of the patients used substances, 54% were diagnosed with SSD, and 47% were antipsychotic naïve. The occurrence of side effects in total was not different in patients with substance use compared to without after 4-weeks of treatment, nor in the follow-up period. At 4-weeks there were some group differences in relation to substance use, diagnosis, and medication history for single side effects. Patients with substance use showed more increased dream activity, less reduced salivation, and more gynecomastia. Patients with SSD showed less neurological side effects, orgasm dysfunction, and tension/inner unrest. The medication naïve patients showed increased hypokinesia/akinesia.

CONCLUSION

Substance use alone does not influence the general magnitude of side effects of antipsychotic medication and does not indicate a different prescription practice in patients with psychosis and substance use.

The role of physical pain in global functioning of people with serious mental illness

While people with serious mental illness (SMI) endorse clinical pain at rates on par or exceeding those in the general population, the association between pain and functioning remains unclear. In this paper we present data on the cross-sectional association between clinical pain and global functioning in a large, mixed diagnostic sample of people with SMI. Eight-hundred ninety-eight people diagnosed with bipolar disorder, major depressive disorder, or schizophrenia were administered the Global Assessment Scale and the 12-item Short Form Survey, which includes an assessment of the extent to which the experience of pain interfered with daily activities over the past month. People with major depressive disorder reported higher pain interference than those with schizophrenia and bipolar disorder. The presence of physical health conditions and psychiatric symptoms were also assessed. After controlling for age, gender, psychiatric symptoms, education level, and physical health problems, pain interference in the past month was associated with significantly lower global functioning. The findings suggest that the experience of pain is associated with poorer global functioning across major SMI diagnoses. Moreover, the impact of pain in global functioning appears independent of physical health problems, and thus may warrant routine screening from mental health providers.

Confirmations, advances and recommendations for the daily care of schizophrenia based on the French national FACE-SZ cohort

BACKGROUND

The National FondaMental Centers of Expertise (FACE) for Schizophrenia (SZ) have been created to shorten the gap between research and clinical practice.

OBJECTIVES

To synthetize in a review the 10-year findings issued from the FACE-SZ cohort analyses.

METHODS

More than 1000 patients were evaluated in 10 expert centers since 2010 with a 2-day long comprehensive standardized battery including neuropsychological testes and physical health assessment and followed-up for 3 years.

RESULTS

1. The phase 0 cross-sectional analyses have confirmed well-known data: over-prescription of first-generation antipsychotics, antipsychotic polytherapy and long-term benzodiazepine and under-prescription of clozapine, 13% of drug-induced parkinsonism, 18% of akathisia, a mean duration of untreated psychosis of 18 months, one third of poorly-adherent patients, 24% of metabolic syndrome and 52% of current tobacco smokers with poor care for physical illnesses; a yearly mean financial cost of 15,000 euro/patient. 2. FACE-SZ also yielded additional data in insufficiently explored area: a half of major depression issues (among them one third of undiagnosed major depression and 44% of treated patients with unremitted depression), major depression having a strong impact on Quality of Life independently of negative symptoms, 22% of moderated to severe untreated physical pain. 3. FACE-SZ has explored emerging fields of research, including development of 4 stages- model of schizophrenia, chronic low-grade peripheral inflammation, latent Toxoplasma infection, hypovitaminosis D, and a model for relapse prediction at 2 years.

DISCUSSION

The associated factors and implications for public health programs were discussed. Based on the FACE-SZ findings and literature, the FACE-SZ group has yielded recommendations to improve daily care for schizophrenia and for future research.

Pain in neuropsychiatry: Insights from animal models

Pain is the most common symptom reported in clinical practice, meaning that it is associated with many pathologies as either the origin or a consequence of other illnesses. Furthermore, pain is a complex emotional and sensorial experience, as the correspondence between pain and body damage varies considerably. While these issues are widely acknowledged in clinical pain research, until recently they have not been extensively considered when exploring animal models, important tools for understanding pain pathophysiology. Interestingly, chronic pain is currently considered a risk factor to suffer psychiatric disorders, mainly stress-related disorders like anxiety and depression. Conversely, pain appears to be altered in many psychiatric disorders, such as depression, anxiety and schizophrenia. Thus, pain and psychiatric disorders have been linked in epidemiological and clinical terms, although the neurobiological mechanisms involved in this pathological bidirectional relationship remain unclear. Here we review the evidence obtained from animal models about the co-morbidity of pain and psychiatric disorders, placing special emphasis on the different dimensions of pain.

A modality-specific dysfunction of pain processing in schizophrenia

Clinical observations showed that schizophrenia (SCZ) patients reported little or no pain under various conditions that are commonly associated with intense painful sensations, leading to a higher risk of morbidity and mortality. However, this phenomenon has received little attention and its underlying neural mechanisms remain unclear. Here, we conducted two experiments combining psychophysics, electroencephalography (EEG), and functional magnetic resonance imaging (fMRI) techniques to investigate neural mechanisms of pain insensitivity in SCZ patients. Specifically, we adopted a stimulus-response paradigm with brief stimuli of different sensory modalities (i.e., nociceptive, non-nociceptive somatosensory, and auditory) to test whether pain insensitivity in SCZ patients is supra-modal or modality-specific, and used EEG and fMRI techniques to clarify its neural mechanisms. We observed that perceived intensities to nociceptive stimuli were significantly smaller in SCZ patients than healthy controls, whereas perceived intensities to non-nociceptive somatosensory and auditory stimuli were not significantly different. The behavioral results were confirmed by stimulus-evoked brain responses sampled by EEG and fMRI techniques, thus verifying the modality-specific nature of the modulation of nociceptive information processing in SCZ patients. Additionally, significant group differences were observed in the spectral power of alpha oscillations in prestimulus EEG and the seed-based functional connectivity in resting-state fMRI (seeds: the thalamus and periaqueductal gray that are key nodes in ascending and descending pain pathways respectively), suggesting a possible contribution of cortical-subcortical dysfunction to the phenomenon. Overall, our study provides insight into the neural mechanisms of pain insensitivity in SCZ and highlights a need for systematic assessments of their pain-related diseases.

Diagnostic tests and treatment procedures performed prior to cardiovascular death in individuals with severe mental illness

OBJECTIVE

To examine whether severe mental illnesses (i.e., schizophrenia or bipolar disorder) affected diagnostic testing and treatment for cardiovascular diseases in primary and specialized health care.

METHODS

We performed a nationwide study of 72 385 individuals who died from cardiovascular disease, of whom 1487 had been diagnosed with severe mental illnesses. Log-binomial regression analysis was applied to study the impact of severe mental illnesses on the uptake of diagnostic tests (e.g., 24-h blood pressure, glucose/HbA1c measurements, electrocardiography, echocardiography, coronary angiography, and ultrasound of peripheral vessels) and invasive cardiovascular treatments (i.e., revascularization, arrhythmia treatment, and vascular surgery).

RESULTS

Patients with and without severe mental illnesses had similar prevalences of cardiovascular diagnostic tests performed in primary care, but patients with schizophrenia had lower prevalences of specialized cardiovascular examinations (prevalence ratio (PR) 0.78; 95% CI 0.73-0.85). Subjects with severe mental illnesses had lower prevalences of invasive cardiovascular treatments (schizophrenia, PR 0.58; 95% CI 0.49-0.70, bipolar disorder, PR 0.78; 95% CI 0.66-0.92). The prevalence of invasive cardiovascular treatments was similar in patients with and without severe mental illnesses when cardiovascular disease was diagnosed before death.

CONCLUSION

Better access to specialized cardiovascular examinations is important to ensure equal cardiovascular treatments among individuals with severe mental illnesses.

Pain Modulation Mechanisms in ASD Adults

We tested endogenous pain modulation mechanisms in adults with autism spectrum disorders (ASD). Nineteen ASD adults without intellectual disabilities were included, matched with 19 healthy volunteers on the basis of sex and chronological age. An experimental pain model was used to measure excitatory and inhibitory pain mechanisms in a single session. Statistical analyses indicated that endogenous pain modulation mechanisms in ASD group did not differ significantly from those of healthy adults. The pain scores were very disparate in ASD group with a greater range of extreme scores than in control group. Unlike schizophrenic patients, there was no systematic dysfunction of endogenous excitatory pain modulation mechanisms, but the high variability requires to be wise to interpret the results and formulate conclusion.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness

BACKGROUND

Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia.

METHODS

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses.

RESULTS

Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications.

CONCLUSIONS

Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

The aetiology of social deficits within mental health disorders: The role of the immune system and endogenous opioids

The American National Institute for Mental Health (NIMH) has put out a set of research goals that include a long-term plan to identify more reliable endogenous explanations for a wide variety of mental health disorders (Insel, 2013). In response to this, we have identified a major symptom that underlies multiple mental health disorders - social bonding dysfunction. We suggest that endogenous opioid abnormalities can lead to altered social bonding, which is a symptom of various mental health disorders, including depression, schizophrenia and ASD. This article first outlines how endogenous opioids play a role in social bonding. Then we show their association with the body's inflammation immune function, and review recent literature linking inflammation to mental health 'immunophenotypes'. We finish by explaining how these immunophenotypes may be caused by alterations in the endogenous opioid system. This is the first overview of the role of inflammation across multiple disorders where we provide a biochemical explanation for why immunophenotypes might exist across diagnoses. We propose a novel mechanism of how the immune system may be causing 'sickness-type' behaviours (fatigue, appetite change, social withdrawal and inhibited motivation) in those who have these immunophenotypes. We hope that this novel aetiology can be used as a basis for future research in mental health.