Weight gain and obesity in schizophrenia: epidemiology, pathobiology, and management

Effects of intermittent theta burst stimulation (iTBS) on appetite change and body weight in inpatients with schizophrenia in China: study protocol for a randomised controlled trial

INTRODUCTION

Antipsychotics are likely to cause weight gain owing to increased appetite and other metabolic disturbances in patients with schizophrenia on prolonged medication. Conventional high-frequency repetitive transcranial magnetic stimulation has been employed to treat people with obesity and has shown certain effectiveness. The goal of this clinical trial is to evaluate the efficacy of intermittent theta burst stimulation (iTBS) in ameliorating appetite increase and weight gain induced by antipsychotics in patients with schizophrenia.

METHODS AND ANALYSIS

In this randomised, double-blind, sham-controlled trial, 60 participants will be enrolled and allocated (1:1) to receive active or sham iTBS on the dorsolateral prefrontal cortex for 5 consecutive days. Appetite, body mass index, clinical symptoms, cognitive function and laboratory indicators will be assessed at baseline, after 5 days of treatments, and at 2 weeks and 4 weeks after all treatments. MRI examination will be conducted to detect brain structure, perfusion and functional connectivity. Data analysis will be conducted in a modified intention-to-treat population. The results of the study will provide evidence on the effectiveness and feasibility of iTBS in improving increased appetite induced by antipsychotics and explore the underlying neuroendocrine pathway affected by the intervention. The primary objective is to evaluate the efficacy of iTBS in weight gain in patients with schizophrenia taking antipsychotics. The secondary objective is to identify the neuroendocrine changes related to appetite in response to iTBS by assessing the variables of cognitive control, glucolipid metabolism and brain activity.

ETHICS AND DISSEMINATION

The study protocol has been approved by the National Clinical Medical Research Center Ethics Committee of The Second People's Hospital of Dali Bai Autonomous Prefecture (no: 2023YN3) and The Second Xiangya Hospital (no: 2024K008). Written informed consent will be obtained voluntarily before enrolment. The results will be disseminated through publication in peer-reviewed journals and presentation at international conferences.

TRIAL REGISTRATION NUMBER

NCT05783063.

Randomized Laboratory Study of Single-Dose Cannabis, Dronabinol, and Placebo in Patients With Schizophrenia and Cannabis Use Disorder

BACKGROUND AND HYPOTHESIS

Up to 43% of people with schizophrenia have a lifetime cannabis use disorder (CUD). Tetrahydrocannabinol (THC) has been shown to exacerbate psychosis in a dose-dependent manner, but little research has assessed its effects on schizophrenia and co-occurring CUD (SCZ-CUD). In this double-dummy, placebo-controlled trial (total n = 130), we hypothesized that a modest dose of THC would worsen cognitive function but not psychosis.

STUDY DESIGN

Effects of single-dose oral THC (15 mg dronabinol) or smoked 3.5% THC cigarettes vs placebo in SCZ-CUD or CUD-only on positive and negative symptoms of schizophrenia (only for SCZ-CUD), cognition, and drug experiences assessed several hours after drug administration. SCZ-only and healthy control participants were also assessed.

STUDY RESULTS

Drug liking was higher in THC groups vs placebo. Neither smoked THC nor oral dronabinol predicted positive or negative symptom subscale scores 2 and 5 h, respectively, after drug exposure in SCZ-CUD participants. The oral dronabinol SCZ-CUD group, but not smoked THC SCZ-CUD group, performed worse than placebo on verbal learning (B = -9.89; 95% CI: -16.06, -3.18; P = .004) and attention (B = -0.61; 95% CI: -1.00, -0.23; P = .002). Every 10-point increment in serum THC + THCC ng/ml was associated with increased negative symptoms (0.40 points; 95% CI: 0.15, 0.65; P = .001; subscale ranges 7-49) and trends were observed for worse positive symptoms and performance in verbal learning, delayed recall, and working memory.

CONCLUSIONS

In people with SCZ-CUD, a modest single dose of oral THC was associated with worse cognitive functioning without symptom exacerbation several hours after administration, and a THC dose-response effect was seen for negative symptoms.

The impacts of antipsychotic medications on eating-related outcomes: A mixed methods systematic review

BACKGROUND

Almost all antipsychotics are associated with weight gain. Given the gravity of this side-effect and its consequences, it is imperative to understand the mechanisms involved. One mechanism that could contribute to this side effect is the impact of antipsychotics on eating-related outcomes.

OBJECTIVE

We aimed to synthesise the available quantitative research on the effects of first- and second-generation antipsychotics on eating-related outcomes, and qualitative research exploring people's experiences with these medications in relation to appetite and eating behaviours (PROSPERO protocol CRD42022340211).

METHODS

We searched Medline, PsycInfo, and Web of Science from inception to 9 May 2024. Quantitative data were synthesised without meta-analysis using vote counting based on direction of effect. Qualitative data were synthesised using thematic synthesis.

RESULTS

Searches identified 8,746 citations yielding 61 separate studies; 55 quantitative and 6 qualitative, published 1982-2024. Using GRADE, our assessment of the quantitative review findings ranged from low to very low-level certainty. Given the lack of direct evidence from high-quality placebo-controlled trials, it is pertinent to interpret the quantitative findings with caution. Using GRADE-CERQual, our assessment of the qualitative review findings ranged from low to very low-level certainty; these findings suggest that the relationship between antipsychotics and food intake is influenced by an interplay of individual, interpersonal and external factors, the most significant of which is food environment.

LIMITATIONS

The internal validity of this review was affected by the serious limitations of the included quantitative studies and the paucity of qualitative evidence.

STRENGTHS

We used GRADE and GRADE-CERQual frameworks to enhance the transparency of our judgement of the certainty of the evidence. Lived experience perspectives were incorporated in different stages of the review to enhance its relevance and practical implications.

CONCLUSIONS

There is insufficient evidence from well-conducted studies to determine the effect of antipsychotics on eating-related outcomes.

"My Body Changed a Lot After Taking Medication. I'm Trying to Hide It but…" A Qualitative Exploration of Body Image Experiences of Women Living With Schizophrenia

Although body image is one of the essential concepts that should be addressed in comprehensive care, the question of how body image affects women with schizophrenia remains unanswered. This study aimed to explore the body image experiences of women living with schizophrenia. This study employed a qualitative approach and participants were recruited from a community mental health center in Türkiye. Semi-structured interviews were conducted with 18 women with schizophrenia. Data were analysed via content analysis. The data were categorised into five themes: (i) body image evaluation, (ii) factors affecting body image, (iii) effects of body image distortion, (iv) coping with body image challenges and (v) protective factors. Schizophrenia affects body functionality, appearance and the self. Women living with schizophrenia experience feelings of shame, sadness, worthlessness and anger related to their body appearance. Body image distortion leads to social distancing and treatment compliance problems. Mental health nurses should support patients to express their feelings and thoughts about the body and recognise their beliefs about ideal body image. Patients should be supported with psychoeducational interventions in the management of symptoms associated with body image disturbance such as weight gain, galactorrhea, sedation and hypersalivation.

Improving the physical health of overweight/obese people suffering from severe mental disorders: What is the role of antipsychotic drugs and of lifestyle psychosocial interventions?

People with severe mental disorders experience premature mortality compared with the general population. Several factors contribute to the mortality gap, including the adoption of unhealthy lifestyle behaviours, poor screening for physical illnesses, difficulties in accessing healthcare facilities, specific clinical features of mental disorders and some pharmacological treatment such as antipsychotic medications with serious metabolic side effects. In the present study, carried out in the framework of the LIFESTYLE trial, a funded nationwide multicentric study, we aimed to assess the impact of different antipsychotics in mediating the effectiveness of psychosocial intervention on healthy lifestyle behaviours. The antipsychotics have been grouped in metabolically more problematic (MMP) vs. metabolically less problematic (MLP). The final sample consists of 401 participants with a mean age of 45.6 ± 11.8 years, mainly female (57.1%), suffering from bipolar disorder (43.4%), schizophrenia spectrum disorders (29.7%) and depressive disorders (26.9%). 36.2% of patients (N = 145) received MMP antipsychotics, 32.2% were treated with MLP antipsychotics and 31.6% did not take any antipsychotic medication, but were treated with antidepressants, mood stabilizers and/or benzodiazepines. At 6-month follow-up, patients receiving the experimental lifestyle intervention and treated with MLP medication reported a significant reduction in BMI (p < .05). Our findings clearly indicate that a multilevel, personalized and individualized therapeutic approach for the treatment of patients with severe mental disorders is needed, with the involvement of different physicians and health providers for an appropriate long-term management of patients with severe mental disorders.

Psychological Distress, Antipsychotic Medications and Cardiovascular Risk Factors Among Patients With Schizophrenia

AIMS

This study aims to assess the correlation between antipsychotic drug use, psychological distress and cardiovascular risk factors among patients with schizophrenia.

METHODS

A cross-sectional correlational design was used to obtain data from 143 patients with schizophrenia who were conveniently selected. Data were collected by assessing selected cardiovascular risk indicators blood pressure (BP), random blood sugar (RBS), body mass index (BMI), waist-to-height ratio (WtHR) and waist circumference (WC). A self-administered questionnaire was used to collect sociodemographic data, clinical history and the 18-item Psychological Stress Index for patients with schizophrenia.

RESULTS

The use of antipsychotics was associated with increased cardiovascular risk factors including BP, BMI and WtHR. Atypical antipsychotic medications were associated with weight gain and obesity which increase the risk of diabetes and cardiovascular diseases. Age was significantly correlated with systolic BP (r = 0.31), diastolic BP (r = 0.30) and RBS (r = 0.26). Furthermore, significant correlations were found between the duration of diagnosis with systolic (r = 0.26) and diastolic (r = 0.21) BP. None of the correlations between stress and the other study variables were significant.

CONCLUSION

Screening of antipsychotic side effects is needed in the early phases, and attention must be paid to the cardiovascular risk in patients with schizophrenia, particularly BP, glucose level and BMI. In addition, clinicians should be informed of this evidence to set guidelines for regular monitoring of metabolic parameters.

REPORTING METHOD

STROBE guidelines were followed in this study.

PATIENT OR PUBLIC CONTRIBUTION

Actively involving patients in data collection, this study ensured that their voices were heard and their experiences were central to informing the research findings. In addition, involving patients in the study would enhance the relevance and applicability of the study's conclusions to real-world contexts, promoting patient-centered care and improved health outcomes for patients with schizophrenia.

Targeting histamine in metabolic syndrome: Insights and therapeutic potential

Metabolic syndrome is a complex disorder defined by a cluster of interconnected factors including obesity, insulin resistance, hypertension, hyperlipidemia and hyperglycemia which increase the risk of cardiovascular disease, non-alcoholic fatty liver disease, type 2 diabetes mellitus and other related diseases. Histamine, as a biogenic amine, participates in various physiological processes. Increasing evidence suggests histamine plays critical roles in Metabolic syndrome as well as its associated diseases by interacting with four histamine receptors. In this review, we summarize the functions and mechanisms of histamine in Metabolic syndrome, indicating histamine as a possible target in treating Metabolic syndrome and its associated diseases.

Individuals with psychosis receive less electric field strength during transcranial direct current stimulation compared to healthy controls

Recent research has examined the effectiveness of transcranial direct current stimulation (tDCS) as an adjunctive treatment for antipsychotics, finding mixed results on cognitive, positive, and negative symptoms. We tested if individuals with psychosis have reduced electric field strength compared to healthy controls and assessed the potential causal factors. We hypothesized that either cortical thinning due to the disorder or increased scalp thickness due to secondary effects of the disorder were causal factors. Using the Psychosis Human Connectome Project dataset, we simulated electric field models for 136 individuals with psychosis, 73 first-degree relatives, and 43 healthy controls. We compared group differences of electric field strength at bilateral dorsolateral prefrontal cortex (dlPFC), targeted with two montages (Fp1-Fp2 & F3-Fp2) commonly used to treat cognitive impairment. We additionally compared groups on scalp, skull, and cerebrospinal fluid thickness at bilateral dlPFC and the three electrode locations. Mediation analyses assessed if tissue thickness and BMI were causal factors for group differences while controlling for age and sex. Individuals with psychosis had lower electric field strength for bilateral dlPFC for both montages. Scalp thickness was also greater for individuals with psychosis, but cerebrospinal fluid thickness was not significantly different. BMI was a significant mediator for the group difference seen in both scalp thickness and electric field strength. Future treatment studies using tDCS in the psychosis population should include electric field modeling to assess its effectiveness given the increased risk of obesity. Individualized montages based on head models may also improve effectiveness.

Effects of Chitosan and N-Succinyl Chitosan on Metabolic Disorders Caused by Oral Administration of Olanzapine in Mice

BACKGROUND

The issue of human mental health is gaining more and more attention nowadays. However, most mental disorders are treated with antipsychotic drugs that cause weight gain and metabolic disorders, which include olanzapine (OLZ). The search for and development of natural compounds for the prevention of obesity when taking antipsychotic drugs is an urgent task. The biopolymer chitosan (Chi) and its derivatives have lipid-lowering and anti-diabetic properties, which makes them potential therapeutic substances for use in the treatment of metabolic disorders. The purpose of this work was to analyze the effect of the natural biopolymer Chi, its derivative N-succinyl chitosan (SuChi), and Orlistat (ORL) as a control on the effects caused by the intake of OLZ in a mouse model.

METHODS

Mice were fed with pearl barley porridge mixed with OLZ or combinations OLZ + Chi, OLZ + SuChi, or OLZ + ORL for 2 months. The weight, lipid profile, blood chemokines, expression of genes associated with appetite regulation, and behavior of the mice were analyzed in dynamics.

RESULTS

For the first time, data were obtained on the effects of Chi and SuChi on metabolic changes during the co-administration of antipsychotics. Oral OLZ increased body weight, food and water intake, and glucose, triglyceride, and cholesterol levels in blood. ORL and SuChi better normalized lipid metabolism than Chi, decreasing triglyceride and cholesterol levels. OLZ decreased the production of all chemokines tested at the 4th week of treatment and increased CXCL1, CXCL13, and CCL22 chemokine levels at the 7th week. All of the supplements corrected the level of CXCL1, CXCL13, and CCL22 chemokines but did not recover suppressed chemokines. SuChi and ORL stimulated the expression of satiety associated proopiomelanocortin (POMC) and suppressed the appetite-stimulating Agouti-related protein (AgRP) genes. All supplements improved the locomotion of mice.

CONCLUSIONS

Taken collectively, we found that SuChi more than Chi possessed an activity close to that of ORL, preventing metabolic disorders in mice fed with OLZ. As OLZ carries positive charge and SuChi is negatively charged, we hypothesized that SuChi's protective effect can be explained by electrostatic interaction between OLZ byproducts and SuChi in the gastrointestinal tract.

Risk factors, prevention and treatment of weight gain associated with the use of antidepressants and antipsychotics: a state-of-the-art clinical review

INTRODUCTION

People with severe mental illness have poor cardiometabolic health. Commonly used antidepressants and antipsychotics frequently lead to weight gain, which may further contribute to adverse cardiovascular outcomes.

AREAS COVERED

We searched MEDLINE up to April 2023 for umbrella reviews, (network-)meta-analyses, trials and cohort studies on risk factors, prevention and treatment strategies of weight gain associated with antidepressants/antipsychotics. We developed 10 clinical recommendations.

EXPERT OPINION

To prevent, manage, and treat antidepressant/antipsychotic-related weight gain, we recommend i) assessing risk factors for obesity before treatment, ii) monitoring metabolic health at baseline and regularly during follow-up, iii) offering lifestyle interventions including regular exercise and healthy diet based on patient preference to optimize motivation, iv) considering first-line psychotherapy for mild-moderate depression and anxiety disorders, v)choosing medications based on medications' and patient's weight gain risk, vi) choosing medications based on acute vs long-term treatment, vii) using effective, tolerated medications, viii) switching to less weight-inducing antipsychotics/antidepressants where possible, ix) using early weight gain as a predictor of further weight gain to inform the timing of intervention/switch options, and x) considering adding metformin or glucagon-like peptide-1 receptor agonists, or topiramate(second-line due to potential adverse cognitive effects) to antipsychotics, or aripiprazole to clozapine or olanzapine.

Association of obesity to reaction time and visual memory in schizophrenia

Background

Both overweight and cognitive deficits are common among people with schizophrenia (SZ) and schizoaffective disorder. The results in earlier studies have been inconsistent on whether overweight is associated with cognitive deficits in psychotic disorders.

Aims

Our aim in this study was to detect possible associations between obesity and cognitive deficits among study participants with SZ and schizoaffective disorder.

Methods

The study sample included 5382 participants with a clinical diagnosis of SZ or schizoaffective disorder selected from the Finnish SUPER study. Obesity was measured both with body-mass index and waist circumference. The cognitive performance was evaluated with two tests from the Cambridge automated neuropsychological test battery: Reaction time was evaluated with the 5-choice serial reaction time task. Visual memory was evaluated with the paired associative learning test. The final analysis included a total sample of 4498 participants applicable for the analysis of the reaction time and 3967 participants for the analysis of the visual memory.

Results

Obesity measured with body-mass index was associated with better performance in reaction time task among both female and male participants. Among male participants, overweight was associated with better performance in the visual memory test. The waist circumference was not associated with cognitive measures.

Conclusions

The results suggest that obesity in people with SZ or schizoaffective disorder might not be associated with cognitive deficits but instead with better cognitive performance. The results were opposite from earlier literature on the general population. More research is required to better understand whether the results might be partly caused by the differences in the etiology of obesity between the general population and people with SZ.

Longitudinal relationships between BMI and hs-CRP among people with schizophrenia

In people with schizophrenia (PwS), inflammation and metabolic issues significantly increase morbidity and mortality. However, our ability to understand inflammatory-metabolic mechanisms in this population has been limited to cross-sectional studies. This study involved 169 PwS and 156 non-psychiatric comparisons (NCs), aged 25-65, observed between 2012 and 2022 with 0 to 5 follow-ups post-baseline. High-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, was measured via a particle-enhanced immuno-turbidimetric assay. Body mass index (BMI) was used as a proxy for metabolic function. The measurement intervals for hs-CRP and BMI ranged between 6 and 48 months. Linear mixed models (LMM) results revealed that at all time points, PwS has a higher hs-CRP (t (316) = 4.73, p < .001) and BMI (t (315) = 4.13, p < .001) than NCs; however, for BMI, this difference decreased over time (t (524) = -5.15, p < .001). To study interrelationships between hs-CRP and BMI, continuous time structural equational modeling (CTSEM) was used, accounting for uneven measurement intervals. CTSEM results showed that both hs-CRP predicted future BMI (Est. = 12.91, 95 % CI [7.70; 17.88]) and BMI predicted future hs-CRP (Est. = 1.54, 95 % CI [1.00; 2.04]), indicating a bidirectional relationship between inflammation and metabolic function. Notably, the influence of hs-CRP on future BMI was more robust than the other lagged relationship (p = .015), especially in PwS (Est. = 2.43, 95 % CI [0.39; 0.97]). Our study highlights the important role of inflammation in metabolic function and offers insights into potential interventions targeting inflammation in PwS.

Mutual effects of gestational diabetes and schizophrenia: how can one promote the other?: A review

Although the physical complications of gestational diabetes mellitus (GDM) are well known, emerging evidence suggests a significant link with psychiatric conditions such as schizophrenia (SCZ). This review aimed to explore the extent, nature, and implications of the association between GDM and SCZ, exploring how the 2 conditions may reciprocally influence each other. We conducted a comprehensive literature review and, analyzed clinical and mechanistic evidence supporting the mutual effects of GDM and SCZ. This review examined factors such as neurodevelopment and the impact of antipsychotics. The study found that Maternal GDM increases the risk of SCZ in offspring. Conversely, women with SCZ were more prone to hyperglycemic pregnancies. The research highlights significant regional variations in GDM prevalence, with the highest rate in the Middle East, North Africa, and South-East Asia regions. These regional variations may have an impact on the epidemiology of SCZ. Furthermore, this review identifies the potential biological and environmental mechanisms underlying these associations. There is a bidirectional relationship between GDM and SCZ, with each disorder potentially exacerbating the others. This relationship has significant implications for maternal and offspring health, particularly in regions with high GDM prevalence. These findings underline the need for integrated care approaches for women with SCZ during pregnancy and the importance of monitoring and managing GDM to mitigate the risk of SCZ in the offspring. Notably, this study recognizes the need for further research to fully understand these complex interactions and their implications for healthcare.

Multimorbidity and the Etiology of Schizophrenia

PURPOSE OF REVIEW

A global study of multimorbidity in schizophrenia, especially of the association with physical conditions, might offer much needed etiological insights.

RECENT FINDINGS

Our review suggests that life-style factors and medication related to schizophrenia are only part of the explanation of the increase in risk for cardiovascular, metabolic, pulmonary disorders, and some cancers. Positive associations with autoimmune disorders (with the exception of rheumatoid arthritis) and epilepsy are promising avenues of research but to date have not been fully exploited. The same holds for the negative comorbidity seen for rheumatoid arthritis and some cancers (e.g., prostate). As a whole, our review suggests that most of the explored conditions have a different prevalence in schizophrenia than in the general population. Several hypotheses emerged from this review such as the role of immune and genetic factors, of sex hormones, and of more general variability factors.

Sex-Specific Effects of Long-Term Antipsychotic Drug Treatment on Adipocyte Tissue and the Crosstalk to Liver and Brain in Rats

Antipsychotic drug (APD) medication can lead to metabolic dysfunctions and weight gain, which together increase morbidity and mortality. Metabolically active visceral adipose tissue (VAT) in particular plays a crucial role in the etiopathology of these metabolic dysregulations. Here, we studied the effect of 12 weeks of drug medication by daily oral feeding of clozapine and haloperidol on the perirenal fat tissue as part of VAT of male and female Sprague Dawley rats in the context of complex former investigations on brain, liver, and blood. Adipocyte area values were determined, as well as triglycerides, non-esterified fatty acids (NEFAs), glucose, glycogen, lactate, malondialdehyde equivalents, ferric iron and protein levels of Perilipin-A, hormone-sensitive-lipase (HSL), hepcidin, glucose transporter-4 (Glut-4) and insulin receptor-ß (IR-ß). We found increased adipocyte mass in males, with slightly higher adipocyte area values in both males and females under clozapine treatment. Triglycerides, NEFAs, glucose and oxidative stress in the medicated groups were unchanged or slightly decreased. In contrast to controls and haloperidol-medicated rats, perirenal adipocyte mass and serum leptin levels were not correlated under clozapine. Protein expressions of perilipin-A, Glut-4 and HSL were decreased under clozapine treatment. IR-ß expression changed sex-specifically in the clozapine-medicated groups associated with higher hepcidin levels in the perirenal adipose tissue of clozapine-treated females. Taken together, clozapine and haloperidol had a smaller effect than expected on perirenal adipose tissue. The perirenal adipose tissue shows only weak changes in lipid and glucose metabolism. The main changes can be seen in the proteins examined, and probably in their effect on liver metabolism.

New insights into the interaction between polycystic ovary syndrome and psychiatric disorders: A narrative review

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disease characterized by hyperandrogenism, ovulatory dysfunction, and ovarian polycystic changes, which combines with reproductive problems, metabolic disorders, and psychological disorders to exhibit a far-reaching impact on the physical and mental health of women. We reviewed previous research and discovered that psychiatric disorders are more common in PCOS patients and their children, potentially exacerbating the condition and creating a vicious loop. To understand the reasons, relevant articles were collected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines from PubMed, Web of Science, and Cochrane Library, through December 2022. Evidence suggested that PCOS-related clinical manifestations, hyperandrogenism, insulin resistance, obesity, gut dysbiosis, and other variables may increase the risk of psychiatric disorders in patients. In turn, psychiatric disorders may aggravate the pathologic process of PCOS and increase the difficulty of the treatment. We systematically reported the mechanisms underlying the psychiatric disorders-PCOS interactions, intending to provide potential ways to break the vicious cycle and lay the groundwork for future research. However, research on PCOS and psychiatric disorders were still in initial stages, which limited the scope of this review. More studies are needed to further verify our findings.

Effects of Exercise on Structural and Functional Brain Patterns in Schizophrenia-Data From a Multicenter Randomized-Controlled Study

BACKGROUND AND HYPOTHESIS

Aerobic exercise interventions in people with schizophrenia have been demonstrated to improve clinical outcomes, but findings regarding the underlying neural mechanisms are limited and mainly focus on the hippocampal formation. Therefore, we conducted a global exploratory analysis of structural and functional neural adaptations after exercise and explored their clinical implications.

STUDY DESIGN

In this randomized controlled trial, structural and functional MRI data were available for 91 patients with schizophrenia who performed either aerobic exercise on a bicycle ergometer or underwent a flexibility, strengthening, and balance training as control group. We analyzed clinical and neuroimaging data before and after 6 months of regular exercise. Bayesian linear mixed models and Bayesian logistic regressions were calculated to evaluate effects of exercise on multiple neural outcomes and their potential clinical relevance.

STUDY RESULTS

Our results indicated that aerobic exercise in people with schizophrenia led to structural and functional adaptations mainly within the default-mode network, the cortico-striato-pallido-thalamo-cortical loop, and the cerebello-thalamo-cortical pathway. We further observed that volume increases in the right posterior cingulate gyrus as a central node of the default-mode network were linked to improvements in disorder severity.

CONCLUSIONS

These exploratory findings suggest a positive impact of aerobic exercise on 3 cerebral networks that are involved in the pathophysiology of schizophrenia.

CLINICAL TRIALS REGISTRATION

The underlying study of this manuscript was registered in the International Clinical Trials Database, ClinicalTrials.gov (NCT number: NCT03466112, https://clinicaltrials.gov/ct2/show/NCT03466112?term=NCT03466112&draw=2&rank=1) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

Influence of psychopathology and metabolic parameters on quality of life in patients with first-episode psychosis before and after initial antipsychotic treatment

The impact of psychological and physical health on quality of life (QoL) in patients with early psychosis remain relatively unexplored. We evaluated the predictive value of psychopathological and metabolic parameters on QoL in antipsychotic-naïve patients with first-episode psychosis before and after initial antipsychotic treatment. At baseline, 125 patients underwent assessments of psychopathology, prevalence of metabolic syndrome (MetS), and QoL. After 6 weeks of antipsychotic monotherapy, 89 patients were re-investigated. At baseline, the prevalence of MetS was 19.3% (n = 22). After 6 weeks, body weight (1.3 kg, p < 0.001) and body mass index (0.4 kg/m2, p < 0.001) increased, and four additional patients developed MetS. Multivariate linear regression revealed that positive and negative symptoms, and to some degree waist circumference, were predictors of QoL at both time points. Our findings suggest that in the earliest stages of antipsychotic treatment, metabolic side-effects may be less influential on QoL than psychopathological severity.

Exploring the link between functional connectivity of ventral tegmental area and physical fitness in schizophrenia and healthy controls

Decreased physical fitness and being overweight are highly prevalent in schizophrenia, represent a major risk factor for comorbid cardio-vascular diseases and decrease the life expectancy of the patients. Thus, it is important to understand the underlying mechanisms that link psychopathology and weight gain. We hypothesize that the dopaminergic reward system plays an important role in this. We analyzed the seed-based functional connectivity (FC) of the ventral tegmental area (VTA) in a group of schizophrenic patients (n=32) and age-, as well as gender-, matched healthy controls (n=27). We then correlated the resting-state results with physical fitness parameters, obtained in a fitness test, and psychopathology. The FC analysis revealed decreased functional connections between the VTA and the anterior cingulate cortex (ACC), as well as the dorsolateral prefrontal cortex, which negatively correlated with psychopathology, and increased FC between the VTA and the middle temporal gyrus in patients compared to healthy controls, which positively correlated with psychopathology. The decreased FC between the VTA and the ACC of the patient group further positively correlated with total body fat (p = .018, FDR-corr.) and negatively correlated with the overall physical fitness (p = .022). This study indicates a link between decreased physical fitness and higher body fat with functional dysconnectivity between the VTA and the ACC. These findings demonstrate that a dysregulated reward system might also be involved in comorbidities and could pave the way for future lifestyle therapy interventions.

Evaluating the efficacy of the Thai Health Improvement Profile intervention for preventing weight gain in people with early stage psychosis: A randomized controlled trial

OBJECTIVES

To investigate the efficacy of the Thai Health Improvement Profile intervention for preventing clinically significant weight gain in people with early stage psychosis.

METHODS

We undertook a randomised controlled trial from 10/2018 to 05/2021. Participants with early stage psychosis (<5 year duration) were recruited using convenience sampling from the caseloads of community psychiatric nurses in Thailand and randomly allocated to either the Thai Health Improvement Profile intervention or treatment as usual group following baseline assessment. Outcome assessors were blind to group allocation, whereas participants were not. Participants in the intervention group received three monthly (five in total) systematic health checks using the Thai Health Improvement Profile tool, which was used to develop a personal health plan in collaboration with a family member/carer. Nurses supported participants to implement the health plan using behaviour change techniques derived from motivational interviewing. The treatment as usual group consisted of medication and psychosocial support, and no additional intervention was provided. The primary outcome was weight gain (defined as a greater or equal to 7 % increase in weight against baseline) within 1 year.

RESULTS

Fifty-three participants were allocated to the intervention and an equal number to the treatment as usual group. Primary outcome data were available for 30 participants in each group at the 12 month follow-up. We undertook an intention to treat analysis with multiple imputation (to handle the missing data) for the primary outcome. The treatment as usual group was found to have higher odds than the Thai Health Improvement Profile intervention group of gaining ≥7 % of baseline body weight (OR = 6.52; 95 % CI: 1.88-22.65, p = 0.004).

CONCLUSIONS

The Thai Health Improvement Profile intervention was effective at preventing weight gain in people with early stage psychosis at one year, though attrition was relatively high. The results highlight the need for community mental health nurses to adopt a holistic approach, the potential benefits of conducting regular comprehensive health checks and the importance of involving family members when aiming to improve the physical health of people diagnosed with early stage psychosis. A large definitive multi-site randomised controlled trial of the Thai Health Improvement Profile with a longer follow-up is now justified.

TRIAL REGISTRATION

Prospectively registered with the Thai Clinical Trials Registry (reference: TCTR20180305002).

Greater anhedonia scores in healthy individuals are associated with less decline in 24-hour energy expenditure with fasting: Evidence for a link between behavioral traits and spendthrift phenotype

Obesity rates are increasing and affecting mental health. It is important to understand how behavioral traits such as anhedonia are associated with physiologic traits that may predict weight-change in clinical and non-clinical populations. We studied whether 24-hour energy expenditure (24hEE) changes with fasting and overfeeding are associated with anhedonia in a healthy cohort. We performed behavioral assessments (physical anhedonia scale (PAS) and inventory for depressive symptoms (IDS)) followed by measures of 24hEE and urinary catecholamines in a whole-room indirect calorimeter (respiratory chamber) during energy balance, and then randomly during fasting and 2 different overfeeding diets. Participants (n=98) were medically healthy, between 18 and 55 years of age, with normal glucose regulation and weight-stable 6 months before admission. Women were premenopausal and not pregnant. Higher PAS was significantly associated with lesser decrease in 24hEE with fasting and higher urinary catecholamine excretion rates - consistent with spendthrift metabolism. As IDS increased, the association between anhedonia and the change in 24hEE from energy balance to fasting decreased (B-values were lower for change in EE). Here, higher PAS scores may reflect the ability to respond with appropriate homeostatic reactions which balance energy needs. IDS scores blunting this response may explain how anhedonia and depression can lead to weight gain.

The bidirectional association of nonalcoholic fatty liver disease with depression, bipolar disorder, and schizophrenia

Nonalcoholic fatty liver disease (NAFLD) is a complex metabolic-inflammatory disease associated with poor outcomes and decreased quality of life. NAFLD is overrepresented in patients with psychiatric disorders like depression, bipolar disorder, and schizophrenia; however, a comprehensive review on NAFLD and psychiatric disorders remains to be delineated. This review endeavors to investigate the association of NAFLD with psychiatric disorders, including shared pathogenesis and future clinical derivatives. Extant literature suggests that patients with psychiatric disorders (in particular, mood disorders) are more susceptible to the development of NAFLD due to multiple reasons, including but not limited to hypothalamic-pituitary-adrenal axis dysregulation, metabolic syndrome, and chronic perceived stress. Moreover, the clinical manifestations of mood disorders (e.g., anhedonia, psychomotor retardation, lifestyle modification, etc.), and potentially long-term treatment with weight-gaining agents, differentially affect these patients, making them more prone to NAFLD. Considering the increased morbidity associated with both mood disorders and NAFLD, our review recommends regular screenings for NAFLD in select patients with mood disorders exhibiting signs of increased risk (i.e., obesity, metabolic syndrome, diabetes, or family history of NAFLD) for better diagnosis and holistic care of both potentially interrelated conditions.

Weight stigma, welfare stigma, and political values: Evidence from a representative British survey

Obesity-related stigma is increasingly recognised as a public health issue, with serious implications for mental and physical health. However, very little is known about what drives inter-individual differences in obesity-stigmatizing views, and how they are distributed in the population. If views about obesity are not independent of a person's wider beliefs and values, this must be understood so that obesity stigma can be effectively tackled. In a representative sample of British adults aged 18-97 (N = 2186), we explore predictors of weight-stigmatizing attitudes. We consider demographics, socioeconomic position, factors related to one's own weight and health, and beliefs about the causes and consequences of obesity. We explore the role of core political values which predict views about other stigmatized groups, and views about welfare recipients, who are frequently linked with obesity in public and political discourse. Finally, we assess to what extent demographic differences in weight-stigmatizing attitudes are explained by individual body mass index (BMI), attitudes, and beliefs. Consistent with previous studies, women were less weight-stigmatizing than men. People in late middle-age were less weight-stigmatizing than younger or older adults. Adjusted for age and gender, an index of weight-stigmatizing views was positively associated with income, and highest in intermediate categories of education and occupational social class. Weight-stigmatizing attitudes were associated with more right-wing values, more authoritarian values, and more stigmatizing views about welfare recipients. Factors including own BMI, beliefs about causes of obesity, welfare-stigmatizing attitudes and authoritarian values contributed to socioeconomic differences. Weight-stigmatizing attitudes show clear differences between demographic groups, but also vary according to wider social attitudes, beliefs, and a person's core political values. Efforts to reduce weight stigma, and other kinds of stigma, may be more effective if they recognise these links.

Weight and metabolic changes in early psychosis-association with daily quantification of medication exposure during the first hospitalization

BACKGROUND

The most common causes of death in schizophrenia are cardiovascular disorders, which are closely related to metabolic syndrome/obesity. To better understand the development of metabolic alterations early in the course of illness, we quantified daily medication exposure in the first days of the first hospitalization for psychosis and related it to changes in weight and metabolic markers.

STUDY DESIGN

We recruited participants with first episode psychosis (FEP, N = 173) during their first psychiatric hospitalization and compared them to controls (N = 204). We prospectively collected weight, body mass index, metabolic markers, and exact daily medication exposure at admission and during hospitalization.

STUDY RESULTS

Individuals with FEP gained on average 0.97 ± 2.26 BMI points or 3.46 ± 7.81 kg of weight after an average of 44.6 days of their first inpatient treatment. Greater antipsychotic exposure was associated with greater BMI increase, but only in people with normal/low baseline BMI. Additional predictors of weight gain included type of medication and duration of treatment. Medication exposure was not directly related to metabolic markers, but higher BMI was associated with higher TGC, TSH, and lower HDL. Following inpatient treatment, participants with FEP had significantly higher BMI, TGC, prolactin, and lower fT4, HDL than controls.

CONCLUSION

During their first admission, people with FEP, especially those with normal/low baseline BMI, showed a rapid and clinically significant weight increase, which was associated with exposure to antipsychotics, and with metabolic changes consistent with metabolic syndrome. These findings emphasize weight monitoring in FEP and suggest a greater need for caution when prescribing metabolically problematic antipsychotics to people with lower BMI.

[Weight gain and treatment with psychotropic drugs : Background and management]

Psychotropic drug-induced weight gain (PIWG) is a well-known and frequent side effect which is relevant for the prognosis of patients. Individual medications have varying risks for the occurrence of PIWG, and at the same time there are individual risk factors on the part of patients, such as age, gender, metabolic and genetic factors. As the metabolic changes in the context of PIWG result in increased mortality in the long term, it is important to prevent PIWG by appropriate prevention and to intervene in a targeted manner if PIWG has already occurred. Appropriate monitoring is therefore essential. This article provides an overview of underlying mechanisms, risk constellations and possible countermeasures.

Exploring the Association between Schizophrenia and Cardiovascular Diseases: Insights into the Role of Sigma 1 Receptor

Contemporary society is characterized by rapid changes. Various epidemiological, political and economic crises represent a burden to mental health of nowadays population, which may at least partially explain the increasing incidence of mental disorders, including schizophrenia. Schizophrenia is associated with premature mortality by at least 13-15 years. The leading cause of premature mortality in schizophrenia patients is high incidence of cardiovascular diseases. The specific-cause mortality risk for cardiovascular diseases in schizophrenia patients is more than twice higher as compared to the general population. Several factors are discussed as the factor of cardiovascular diseases development. Intensive efforts to identify possible link between schizophrenia and cardiovascular diseases are made. It seems that sigma 1 receptor may represent such link. By modulation of the activity of several neurotransmitter systems, including dopamine, glutamate, and GABA, sigma 1 receptor might play a role in pathophysiology of schizophrenia. Moreover, significant roles of sigma 1 receptor in cardiovascular system have been repeatedly reported. The detailed role of sigma 1 receptor in both schizophrenia and cardiovascular disorders development however remains unclear. The article presents an overview of current knowledge about the association between schizophrenia and cardiovascular diseases and proposes possible explanations with special emphasis on the role of the sigma 1 receptor.

Integrated bioinformatics and statistical approach to identify the common molecular mechanisms of obesity that are linked to the development of two psychiatric disorders: Schizophrenia and major depressive disorder

Obesity is a chronic multifactorial disease characterized by the accumulation of body fat and serves as a gateway to a number of metabolic-related diseases. Epidemiologic data indicate that Obesity is acting as a risk factor for neuro-psychiatric disorders such as schizophrenia, major depression disorder and vice versa. However, how obesity may biologically interact with neurodevelopmental or neurological psychiatric conditions influenced by hereditary, environmental, and other factors is entirely unknown. To address this issue, we have developed a pipeline that integrates bioinformatics and statistical approaches such as transcriptomic analysis to identify differentially expressed genes (DEGs) and molecular mechanisms in patients with psychiatric disorders that are also common in obese patients. Biomarker genes expressed in schizophrenia, major depression, and obesity have been used to demonstrate such relationships depending on the previous research studies. The highly expressed genes identify commonly altered signalling pathways, gene ontology pathways, and gene-disease associations across disorders. The proposed method identified 163 significant genes and 134 significant pathways shared between obesity and schizophrenia. Similarly, there are 247 significant genes and 65 significant pathways that are shared by obesity and major depressive disorder. These genes and pathways increase the likelihood that psychiatric disorders and obesity are pathogenic. Thus, this study may help in the development of a restorative approach that will ameliorate the bidirectional relation between obesity and psychiatric disorder. Finally, we also validated our findings using genome-wide association study (GWAS) and whole-genome sequence (WGS) data from SCZ, MDD, and OBE. We confirmed the likely involvement of four significant genes both in transcriptomic and GWAS/WGS data. Moreover, we have performed co-expression cluster analysis of the transcriptomic data and compared it with the results of transcriptomic differential expression analysis and GWAS/WGS.

Association between Empathy and Clinical Symptoms among Overweight and Non-Overweight Chinese Chronic Schizophrenia Patients

Patients with schizophrenia are afflicted by severe clinical symptoms and serious cognitive dysfunction. The aim of this study is to investigate the potential relationships between clinical symptoms and empathy and their variations between overweight and non-overweight schizophrenia patients. To address this problem, a group of 776 inpatients diagnosed with chronic schizophrenia (504 overweight patients and 272 non-overweight patients) was recruited. The Positive and Negative Syndrome Scale (PANSS) and its five-factor model were employed to assess clinical symptoms, while empathy levels were measured using the Interpersonal Reactivity Index (IRI). The overweight patients had lower education levels but higher positive symptoms than the non-overweight patients (all p < 0.05). In addition, the overweight patients performed significantly better with respect to empathy (FDR-corrected p < 0.05). Additional multiple regression analyses indicated significant associations between the total score of the IRI and PANSS negative symptoms, gender, and family history of psychiatric disorders among the overweight group; among non-overweight patients, there was a significant correlation between suicide and the total score of the IRI. This study provides evidence suggesting that chronic schizophrenia patients who are overweight may have distinct clinical characteristics, particularly with respect to their empathy, compared with non-overweight patients. Moreover, different variables are associated with empathy in different groups.

Association of daily-life functioning and obesity in individuals with schizophrenia and controls

Early weight gain following the diagnosis of schizophrenia (SCZ) has been associated with improved daily functioning. However, in the general population and in other psychiatric conditions such as bipolar disorder, increased body mass index (BMI) has been associated with worse functioning. The data on this association in chronic individuals with SCZ is still scarce. To address this gap in knowledge, our objective was to evaluate the association between BMI and psychosocial functioning in chronic outpatients with SCZ and in healthy individuals. Six-hundred individuals (n = 600), 312 with schizophrenia (SCZ) and 288 individuals with no personal or family history of severe mental illness (CTR), underwent weight, height and psychosocial functioning score (FAST) assessment. Linear regression models tested the association between FAST as dependent variable and BMI as independent variable, controlling for age, sex, use of clozapine and years of illness. In the CTR group, the highest BMI could predict a worse result in FAST, explaining about 22% of the variation found (Model: AdjR2 = 0.225 F(3,284) = 28.79 p < .001; BMI main effect: β = 0.509 t = 9.240 p < .001). In the SCZ group, there was no statistically significant association. Our findings corroborate the perception that increased BMI is associated with worse functioning status in the general population. In chronic SCZ, whatsoever, there is no association. Our findings suggest that patients with higher BMI in the SCZ group may compensate for the possible impairment of functionality due to increased body weight, through improved adherence and responsiveness to prescribed psychopharmacological treatment, leading to better control of psychiatric symptoms.

Investigating the shared genetic architecture between schizophrenia and body mass index

Evidence for reciprocal comorbidity of schizophrenia (SCZ) and body mass index (BMI) has grown in recent years. However, little is known regarding the shared genetic architecture or causality underlying the phenotypic association between SCZ and BMI. Leveraging summary statistics from the hitherto largest genome-wide association study (GWAS) on each trait, we investigated the genetic overlap and causal associations of SCZ with BMI. Our study demonstrated a genetic correlation between SCZ and BMI, and the correlation was more evident in local genomic regions. The cross-trait meta-analysis identified 27 significant SNPs shared between SCZ and BMI, most of which had the same direction of influence on both diseases. Mendelian randomization analysis showed the causal association of SCZ with BMI, but not vice versa. Combining the gene expression information, we found that the genetic correlation between SCZ and BMI is enriched in six regions of brain, led by the brain frontal cortex. Additionally, 34 functional genes and 18 specific cell types were found to have an impact on both SCZ and BMI within these regions. Taken together, our comprehensive genome-wide cross-trait analysis suggests a shared genetic basis including pleiotropic loci, tissue enrichment, and shared function genes between SCZ and BMI. This work provides novel insights into the intrinsic genetic overlap of SCZ and BMI, and highlights new opportunities and avenues for future investigation.

Weight changes following treatment with aripiprazole, risperidone and olanzapine: A 12-month study of first-episode schizophrenia patients in China

OBJECTIVES

This study aimed to assess weight changes following antipsychotic treatment in first-episode schizophrenia (FES) patients and make a comparison of aripiprazole, risperidone and olanzapine. Predictors for long-term clinically relevant weight gain (CRW, ≥7%) were examined.

METHODS

We carried out a second analysis of data from the Chinese First-Episode Schizophrenia Trial. Repeated measures general linear model (GLM) statistics were used to compare body weight at each follow-up point (month of 1, 2, 3, 6, 9and 12). Logistic regression models were constructed to evaluate possible predictors for CRW.

RESULTS

Body weight increased with an average rate of 0.93 % per month, with the fastest growth rate occurring in first 3 months. CRW was observed in 79 % of patients. Participants from olanzapine group showed significantly higher weight gain than risperidone group and aripiprozole group. Repeated measures GLM revealed a significant main effect of time (p < 0.001) and asignificant time*group interaction was revealed (p < 0.001), while the between-subject group effect was not statistically significant (p = 0.272). Multivariate logistic regressionmodel showed that with smaller baseline BMI (OR = 1.33, p < 0.001), with a family history of mental disorder (OR = 5.08, p = 0.004), receiving olanzapine (OR = 2.35, p = 0.001), and CRW at first-month (OR = 4.29, p = 0.032) were independent predictors for first-year CRW.

CONCLUSION

Antipsychotics are associated with a clinically significant weight gain in FES patients, which occurs mostly in first 3 months. Aripiprazole might not be an ideal choice in terms of long-term metabolic side-effects. Early and close metabolic monitoring should accompany antipsychotic prescription.

Cardiovascular risk factors and metabolic syndrome in patients treated with long-acting injectables antipsychotics: a retrospective study

The present cross-sectional, retrospective study aimed to assess the prevalence of cardiovascular disease (CVD) risk factors and metabolic syndrome in a sample of psychiatric patients treated with long-acting injectable antipsychotics (LAIs). The clinical charts of 120 patients, mainly diagnosed with schizophrenia (30.0%), schizoaffective disorder (15.0%), and bipolar disorder (13.3%) on LAIs therapy - initiated in the period from 2013 to 2019 and lasting at least one year - were retrospectively reviewed and related socio-demographic, clinical and laboratory variables were collected. The 70.8% of patients were treated with first-generation LAIs, and the remaining 29.2% with second-generation LAIs. The overall sample showed low compliance in performing the required exams and evaluations related to CVD risk factors. The prevalence of metabolic syndrome was 30.8%, and, considering specific CVD risk factors, 55% of the total sample reported abdominal obesity, 43.3% arterial hypertension, 41.7% low HDL-cholesterol, 25.8% hypertriglyceridemia, and 20.8% fasting hyperglycemia. Lastly, 6.7% showed prolonged corrected QT (QTc) interval at the ECG. Patients treated with LAIs should be regularly monitored for metabolic changes and CVD risk factors. Metabolic changes rapidly develop after initiating an antipsychotic therapy and these often involve parameters, that can be easily recorded in an outpatient setting (e.g. abdominal obesity and hypertension).

Differences in body mass index trajectories of adolescent psychiatric inpatients by sex, age, diagnosis and medication: an exploratory longitudinal, mixed effects analysis

BACKGROUND

Adolescents in secure psychiatric care typically report high obesity rates. However, longitudinal research exploring the rate and extent of change is sparse. This study aimed to analyse sex differences in longitudinal body mass index (BMI) change for adolescents receiving treatment in a secure psychiatric hospital.

METHODS

The sample comprised 670 adolescents in secure psychiatric care. BMI trajectories from admission to 50 months of hospitalisation were produced using sex-stratified multilevel models. Systematic difference in mean BMI trajectories according to age at admission (14, 15, 16, or 17 years), medication (Olanzapine or Sodium Valproate), and primary diagnosis (Psychotic, non-Psychotic or Functional/behavioural disorders) were investigated.

RESULTS

Together, males and females experienced a mean BMI increase of 2.22 m/kg2 over the 50-month period. For females, BMI increased from 25.69 m/kg2 to 30.31 m/kg2 , and for males, reduced from 25.01 m/kg2 to 23.95 m/kg2 . From 30 to 50 months, a plateau was observed for females and a reduction in BMI observed for males. Psychotic disorders in males (β 3.87; CI 1.1-6.7) were associated with the greatest rate of BMI change. For medication, Olanzapine in females was associated with the greatest rate of change (β1.78; CI -.89-4.47).

CONCLUSIONS

This is the first longitudinal study exploring longitudinal BMI change for adolescent inpatients. Results highlight that individual differences in adolescent inpatients result in differing levels of risk to weight gain in secure care. Specifically, males with psychotic disorders and females taking Olanzapine present the greatest risk of weight gain. This has implications for the prioritisation of interventions for those most at risk of weight gain.

Schizophrenia and obesity: May the gut microbiota serve as a link for the pathogenesis?

Schizophrenia (SZ) places a tremendous burden on public health as one of the leading causes of disability and death. SZ patients are more prone to developing obesity than the general population from the clinical practice. The development of obesity frequently causes poor psychiatric outcomes in SZ patients. In turn, maternal obesity during pregnancy has been associated with an increased risk of SZ in offspring, suggesting that these two disorders may have shared neuropathological mechanisms. The gut microbiota is well known to serve as a major regulator of bidirectional interactions between the central nervous system and the gastrointestinal tract. It also plays a critical role in maintaining physical and mental health in humans. Recent studies have shown that the dysbiosis of gut microbiota is intimately associated with the onset of SZ and obesity through shared pathophysiological mechanisms, particularly the stimulation of immune inflammation. Therefore, gut microbiota may serve as a common biological basis for the etiology in both SZ and obesity, and the perturbed gut-brain axis may therefore account for the high prevalence of obesity in patients with SZ. On the basis of these findings, this review provides updated perspectives and intervention approaches on the etiology, prevention, and management of obesity in SZ patients by summarizing the recent findings on the role of gut microbiota in the pathogenesis of SZ and obesity, highlighting the role of gut-derived inflammation.

Psychometric and clinical evaluation of schizophrenia remission criteria in outpatients with psychotic disorders

BACKGROUND

Psychotic disorders such as schizophrenia have debilitating effects on health and functioning. Given symptomatic remission's recent emergence as a viable treatment goal, the Remission in Schizophrenia Working Group's criteria (RSWG-cr), based on eight items from the Positive and Negative Syndrome Scale (PANSS-8), are frequently used in clinical and research settings. Against that background, we sought to evaluate the PANSS-8's psychometric properties and examine the RSWG-cr's clinical validity among outpatients in Sweden.

METHODS

Cross-sectional register data were collected from outpatient psychosis clinics in Gothenburg, Sweden. Following confirmatory and exploratory factor analyses of PANSS-8 data (n = 1,744) to assess the PANSS-8's psychometric properties, internal reliability was evaluated using Cronbach's alpha. Next, 649 of the patients were classified according to the RSWG-cr and their clinical and demographic characteristics compared. Binary logistic regression was used to estimate odds ratios (OR) and assess each variable's impact on remission status.

RESULTS

The PANSS-8 showed good reliability (α = .85), and the 3D model of psychoticism, disorganization, and negative symptoms presented the best model fit. According to the RSWG-cr, 55% of the 649 patients were in remission; they were also more likely to live independently, be employed, not smoke, not take antipsychotics, and have recently received a health interview and physical examination. Patients living independently (OR = 1.98), who were employed (OR = 1.89), who were obese (OR = 1.61), and who had recently received a physical examination (OR = 1.56) also had an increased likelihood of remission.

CONCLUSIONS

The PANSS-8 is internally reliable, and, according to the RSWG-cr, remission is associated with variables of interest for patients' recovery, including living independently and being employed. Although our findings from a large, heterogeneous sample of outpatients reflect everyday clinical practice and reinforce past observations, the directions of those relationships need to be assessed in longitudinal studies.

Mechanism and treatments of antipsychotic-induced weight gain

The long-term use of antipsychotics (APs) may cause a variety of diseases, such as metabolic syndrome, antipsychotic-induced weight gain (AIWG), and even obesity. This paper reviews the various mechanisms of AIWG and obesity in detail, involving genetics, the central nervous system, the neuroendocrine system, and the gut microbiome. The common drug and non-drug therapies used in clinical practice are also introduced, providing the basis for research on the molecular mechanisms and the future selection of treatments.

Polygenic risk scores enhance prediction of body mass index increase in individuals with a first episode of psychosis

BACKGROUND

Individuals with a first episode of psychosis (FEP) show rapid weight gain during the first months of treatment, which is associated with a reduction in general physical health. Although genetics is assumed to be a significant contributor to weight gain, its exact role is unknown.

METHODS

We assembled a population-based FEP cohort of 381 individuals that was split into a Training (n = 224) set and a Validation (n = 157) set to calculate the polygenic risk score (PRS) in a two-step process. In parallel, we obtained reference genome-wide association studies for body mass index (BMI) and schizophrenia (SCZ) to examine the pleiotropic landscape between the two traits. BMI PRSs were added to linear models that included sociodemographic and clinical variables to predict BMI increase (∆BMI) in the Validation set.

RESULTS

The results confirmed considerable shared genetic susceptibility for the two traits involving 449 near-independent genomic loci. The inclusion of BMI PRSs significantly improved the prediction of ∆BMI at 12 months after the onset of antipsychotic treatment by 49.4% compared to a clinical model. In addition, we demonstrated that the PRS containing pleiotropic information between BMI and SCZ predicted ∆BMI better at 3 (12.2%) and 12 months (53.2%).

CONCLUSIONS

We prove for the first time that genetic factors play a key role in determining ∆BMI during the FEP. This finding has important clinical implications for the early identification of individuals most vulnerable to weight gain and highlights the importance of examining genetic pleiotropy in the context of medically important comorbidities for predicting future outcomes.

Examining Factors Associated with Dynapenia/Sarcopenia in Patients with Schizophrenia: A Pilot Case-Control Study

Sedentary behavior in patients with schizophrenia causes muscle weakness, is associated with a higher risk of metabolic syndrome, and contributes to mortality risk. This pilot case-control study aims to examine the associated factors for dynapenia/sarcopenia in patients with schizophrenia. The participants were 30 healthy individuals (healthy group) and 30 patients with schizophrenia (patient group), who were matched for age and sex. Descriptive statistics, Welch's t-test, cross-tabulations, adjusted residuals, Fisher's exact probability test (extended), and/or odds ratios (ORs) were calculated. In this study, dynapenia was significantly more prevalent in patients with schizophrenia than in healthy individuals. Regarding body water, Pearson's chi-square value was 4.41 (p = 0.04), and significantly more patients with dynapenia were below the normal range. In particular, body water and dynapenia showed a significant association, with an OR = 3.42 and 95% confidence interval [1.06, 11.09]. Notably, compared with participants of the healthy group, patients with schizophrenia were overweight, had less body water, and were at a higher risk for dynapenia. The impedance method and the digital grip dynamometer used in this study were simple and useful tools for evaluating muscle quality. To improve health conditions for patients with schizophrenia, additional attention should be paid to muscle weakness, nutritional status, and physical rehabilitation.

Psychotic-like experiences are associated with physical disorders in general population: A cross-sectional study from the NESARC II

BACKGROUND

Psychotic-like experiences (PLEs) constitute subthreshold symptoms of psychotic disorders, and belong to five distinct dimensions: Positive, Negative, Depressive, Mania and Disorganization. PLEs are associated with various psychiatric disorders. However, few studies examined their association with physical disorders.

OBJECTIVE

Our aims were (1) to assess the associations between various physical disorders and PLEs in a U.S. representative sample, and (2) to examine these associations according to the five dimensions of PLEs.

METHOD

We used data from the wave II (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-II), a large national sample representative of the US population (N = 34,653). Participants were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule 4. Twenty-two PLEs were examined. Lifetime prevalence and adjusted Odds-Ratio (aOR) reflecting the association of sixteen physical disorders (including notably metabolic conditions and heart diseases) with PLEs were calculated.

RESULTS

All studied physical disorders were associated with the presence of PLEs. Particularly the presence of any physical condition, any heart disease and diabetes were more frequent in participants with at least one PLE compared with the group without any PLE (aOR = 1.74, 95% CI = 1.62-1.87, aOR = 1.44, 95% CI = 1.33-1.55 and aOR = 1.38, 95% CI = 1.24-1.54, respectively). Almost all physical disorders were associated with the five dimensions of PLEs.

CONCLUSIONS

PLEs were associated with a large range of physical disorders, with a gradual dose effect. To assess PLEs in the general population could help with the screening of subjects with physical disorders.

Association between antipsychotic medication and clinically relevant weight change: meta-analysis

BACKGROUND

Previous meta-analyses have shown that almost all antipsychotics are associated with weight gain. However, mean weight gain is not informative about clinically relevant weight gain or weight loss.

AIMS

To provide further insight into the more severe body weight changes associated with antipsychotic use, we assessed the proportion of patients with clinically relevant weight gain (CRWG) and clinically relevant weight loss (CRWL), defined as ≥7% weight gain and ≥7% weight loss.

METHOD

We searched PubMed, Embase and PsycInfo for randomised controlled trials of antipsychotics that reported CRWG and CRWL in study populations aged 15 years or older. We conducted meta-analyses stratified by antipsychotic and study duration using a random-effects model. We performed meta-regression analyses to assess antipsychotic-naive status and psychiatric diagnosis as modifiers for CRWG. PROSPERO: CRD42020204734.

RESULTS

We included 202 articles (201 studies). Almost all included antipsychotics were associated with CRWG. For CRWL, available data were too limited to draw firm conclusions. For some antipsychotics, CRWG was more pronounced in individuals who were antipsychotic-naive than in individuals switching to another antipsychotic. Moreover, a longer duration of antipsychotic use was associated with more CRWG, but not CRWL. For some antipsychotics, CRWG was higher in people diagnosed with schizophrenia, but this was inconsistent.

CONCLUSIONS

Switching antipsychotic medication is associated with both weight gain and weight loss, but the level of CRWG is higher than CRWL in antipsychotic-switch studies. CRWG was more pronounced in antipsychotic-naive patients, highlighting their vulnerability to weight gain. The impact of diagnosis on CRWG remains inconclusive.

Effect of Repetitive Transcranial Magnetic Stimulation in Inducing Weight Loss in Patients with Chronic Schizophrenia: A Randomized, Double-Blind Controlled 4-Week Study

OBJECTIVES

There is emerging evidence that high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) may promote weight loss in individuals with obesity in the general population. However, no study has been conducted on patients with schizophrenia (SZ). This study evaluated the efficacy of 10Hz rTMS in reducing body weight in patients with chronic SZ.

METHODS

Forty-seven SZ patients were randomly assigned to two groups: 10Hz rTMS or sham stimulation over DLPFC (applied once daily) for 20 consecutive treatments. Body weight was assessed at baseline, at the end of week 1, week 2, week 3 and week 4. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of week 4.

RESULTS

We found that compared with patients in the sham group, 10Hz rTMS treatment significantly reduced body weight in patients with chronic SZ after a period of 4 weeks of stimulation. Interestingly, further analysis found that from the first week (5 sessions) of treatment, there was a significant difference in body weight between active and sham groups after controlling for baseline weight. However, active rTMS treatment did not improve the psychotic symptoms compared to sham stimulation.

CONCLUSION

Our results suggest that add-on HF rTMS could be an effective therapeutic strategy for body weight control in patients with chronic SZ.

Weight changes in people with early psychosis treated with oral or long-acting injectable aripiprazole

OBJECTIVES

Weight gain remains a major problem in young people with psychosis treated with antipsychotic medication. Aripiprazole is now available in monthly long-acting injection (LAI) and daily oral tablet formulation, but information is lacking about differences in weight gain between the two formulations. We monitored for up to 24 months the weight changes associated with oral or LAI-administered aripiprazole and in a group who not prescribed any antipsychotic medication.

METHODS

Participants included 109 young people with early psychosis (n = 30 Oral, 41 LAI, 38 Nil antipsychotic) with a treatment completion median time of 15 months. Weight (kilogram) and body mass index (BMI) were recorded at 3 monthly intervals. Multilevel modelling analyses assessed the contribution of time and group on weight change.

RESULTS

Participants taking nil antipsychotics did not gain weight over time, while the two aripiprazole groups gained a combined average of 7.1 kg (SD = 5.0) or 1.9 BMI (SD = 0.4). An examination of formulation effects showed a significantly greater rate of change over time in the Oral group with a weight increase of approximately 11.0 kg (SD = 8.2) or 3.5 BMI (SD = 0.7, compared to the LAI group with a gain of 3.7 kg (SD = 2.1) or 0.8 BMI (SD = 0.1) in the LAI group. These differences could not be explained by demographic or clinical characteristics, medication dosage, or baseline weight.

CONCLUSIONS

While aripiprazole is generally considered relatively benign in terms of weight, it still poses a significant risk especially for people with early psychosis. However the current study suggests that the risk may be lower in those treated with LAI than with Oral formulation, consolidating the clinical utility of LAI.

Relatives' experiences of an equine-assisted intervention for people with psychotic disorders

PURPOSE

The aim of this study was to describe relatives' experiences of an equine-assisted intervention for people with psychotic disorders.

METHODS

The study has a qualitative and descriptive design. Ten semi-structured interviews were performed with relatives of people with a psychotic disorder who had participated in an equine-assisted intervention. A conventional content analysis was used to analyse the data.

RESULT

The overall category "Being with the horses strengthens health capabilities" summarizes the four identified subcategories "The horses contribute to a context with a common focus", "Interaction with the horses enhances self-confidence and motivation", "The interplay with the horses nurtures positive emotions" and "Being with the horses encourages physical activity".

CONCLUSIONS

The result of this study contributes to the growing body of research about the potential outcomes of equine-assisted interventions. The result also indicates that equine-assisted interventions may improve health capabilities among people with psychotic disorders. The generated knowledge may be useful in mental health services when developing equine-assisted interventions.

Polypharmacy Management of Antipsychotics in Patients with Schizophrenia

Schizophrenia is a chronic psychiatric disease that is characterized by psychotic symptoms, including positive, negative, affective, and aggressive symptoms, as well as cognitive dysfunction, and is primarily treated using drug therapy, the continuation of which is essential to prevent recurrence/recrudescence. Various second-generation antipsychotics with pharmacological properties or adverse events that differ from those of conventional antipsychotics have recently been introduced, and pharmaceutical management is required for drug efficacy assessments and adverse event monitoring/management of these drugs. Antipsychotic monotherapy (APM) is the gold standard treatment for schizophrenia and is recommended in various guidelines. However, a subgroup of patients with schizophrenia do not or only partially respond to APM. Therefore, antipsychotic polypharmacy (APP), in which ≥2 antipsychotics are combined, has been routinely utilized to compensate for insufficient responses to APM in clinical practice. APP has recently been proposed as an evidence-based treatment option, but does not consider clinicians' experience. However, the risk of APP-related adverse events is high. The application of APP needs to be carefully reviewed, whilst taking into consideration patient backgrounds. Furthermore, the risk of APP-related adverse events is higher in elderly patients than in the general population; therefore, caution is needed. This review discusses the merits of APP, matters that need to be considered, and a switch from APP to APM, and also focuses on the application of APP in clinical practice.

Drug-drug interactions involving combinations of antipsychotic agents with antidiabetic, lipid-lowering, and weight loss drugs

INTRODUCTION

Patients with severe mental illness (SMI) have a high risk for diabetes, dyslipidemia, and other components of metabolic syndrome. Patients with these metabolic comorbidities and cardiac risk factors should receive not only antipsychotics but also medications aiming to reduce cardiovascular risk. Therefore, many patients may be exposed to clinically relevant drug-drug interactions.

AREAS COVERED

This narrative review summarizes data regarding the known or potential drug-drug interactions between antipsychotics and medications treating metabolic syndrome components, except for hypertension, which has been summarized elsewhere. A literature search in PubMed and Scopus up to 7/31/2021 was performed regarding interactions between antipsychotics and drugs used to treat metabolic syndrome components, aiming to inform clinicians' choice of medication for patients with SMI and cardiometabolic risk factors in need of pharmacologic interventions.

EXPERT OPINION

The cytochrome P450 system and, to a lesser extent, the P-glycoprotein transporter is involved in the pharmacokinetic interactions between antipsychotics and some statins or saxagliptin. Regarding pharmacodynamic interactions, the available information is based mostly on small studies, and for newer classes, like PCSK9 inhibitors or SGLT2 inhibitors, data are still lacking. However, there is sufficient information to guide clinicians in the process of selecting safer antipsychotic-cardiometabolic risk reduction drug combinations.

Gray matter reduction in bilateral insula mediating adverse psychiatric effects of body mass index in schizophrenia

BACKGROUND

Both schizophrenia (SZ) and overweight/obesity (OWB) have shown some structural alterations in similar brain regions. As higher body mass index (BMI) often contributes to worse psychiatric outcomes in SZ, this study was designed to examine the effects of OWB on gray matter volume (GMV) in patients with SZ.

METHODS

Two hundred fifty subjects were included and stratified into four groups (n = 69, SZ patients with OWB, SZ-OWB; n = 74, SZ patients with normal weight, SZ-NW; n = 54, healthy controls with OWB, HC-OWB; and n = 53, HC with NW, HC-NW). All participants were scanned using high-resolution T1-weighted sequence. The whole-brain voxel-based morphometry was applied to examine the GMV alterations, and a 2 × 2 full factorial analysis of variance was performed to identify the main effects of diagnosis (SZ vs HC), BMI (NW vs OWB) factors, and their interactions. Further, the post hoc analysis was conducted to compare the pairwise differences in GMV alterations.

RESULTS

The main effects of diagnosis were located in right hippocampus, bilateral insula, rectus, median cingulate/paracingulate gyri and thalamus (SZ < HC); while the main effects of BMI were displayed in right amygdala, left hippocampus, bilateral insula, left lingual gyrus, and right superior temporal gyrus (OWB < NW). There were no significant diagnosis-by-BMI interaction effects in the present study, but the results showed that both SZ and OWB were additively associated with lower GMV in bilateral insula. Moreover, mediation analyses revealed the indirect effect of BMI on negative symptom via GMV reduction in bilateral insula.

CONCLUSION

This study further supports that higher BMI is associated with lower GMV, which may increase the risk of unfavourable disease courses in SZ.

Is there a therapeutic potential in combining bupropion and naltrexone in schizophrenia?

INTRODUCTION

A sustained-release tablet composed of a combination of the dopamine and norepinephrine reuptake inhibitor bupropion (BUP) and the µ-opioid receptor antagonist naltrexone (NAT) is marketed under the brand name Contrave by Orexigen Therapeutics for appetite control. Minimal literature is available regarding the use of combination bupropion and naltrexone (BUPNAT) in individuals with schizophrenia.

AREAS COVERED

In this review, we propose a theoretical model where BUPNAT may have a therapeutic effect in the treatment of schizophrenia. We explore the pathways targeted by the constituent drugs BUP and NAT and summarize the literature on their efficacy and possible adverse effects. We then look at the potential use of BUPNAT in schizophrenia.

EXPERT OPINION

Research has hinted that BUP's dopaminergic properties affect the same striatal pathways involved in schizophrenia. NAT, via opioid receptor antagonism, indirectly increases striatal dopamine release by disinhibiting nicotinic acetylcholine receptors. As such, we hypothesize that BUPNAT can have a therapeutic effect in schizophrenia, particularly on negative symptoms. We also suggest that it may ameliorate comorbidities frequently seen in this group of patients, including obesity, smoking, and substance use. Further research and clinical data are needed to elucidate the potential clinical benefits of BUPNAT in the treatment of schizophrenia.