Obesity among individuals with serious mental illness

Psychiatric Explanations of Poor Oral Intake: A Clinically Focused Review

BACKGROUND

Poor oral intake (POI) among medical-surgical inpatients can cause malnutrition and delay recovery due to medical consequences and the need for more invasive nutritional support. Many psychiatric conditions can cause POI; however, the role that psychiatric conditions play in POI has received limited attention to date.

OBJECTIVE

This review aggregates available information on POI due to psychiatric conditions and provides a framework for the clinical approach to these conditions in hospitalized adult patients.

METHODS

We searched PubMed and EMBASE for reviews of POI due to psychiatric causes, but no relevant publications were identified. Diagnostic criteria for relevant conditions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision and Rome IV were reviewed, as were C-L psychiatry textbooks and relevant society websites. This review was further supplemented by a case conference at the authors' institution.

RESULTS

We have divided results into five sections for clinical utility: (1) the need to rule out medical causes of POI; (2) unpleasant somatic experiences, including psychotropic causes; (3) mood, psychotic, catatonic, and neurocognitive disorders that can present with POI; (4) eating and feeding disorders; and (5) personal and interpersonal explanations of POI. Within each section, we review how to identify and manage each condition, specifically considering the effects of treatment on oral intake.

CONCLUSIONS

The clinical management of POI varies based on cause. For instance, psychostimulants can cause POI due to inappetence; however, they can treat POI due to abulia by improving motivation. The fact that such a broad range of psychiatric conditions can cause POI calls for a systematic clinical approach that considers the categories of potential causes. We also identified a need for prospective studies focused on the management of POI due to psychiatric conditions, as the literature on this topic is limited to case reports, case series, and retrospective cohort studies.

Adaptation of the Barriers, Attitudes, Confidence, and Knowledge Scale (M-BACK-Tr) into Turkish culture to assess the metabolic health of psychiatric professionals and investigation of Its psychometric characteristics

AIM

The aim was to evaluate the validity and reliability of the "Barriers, Attitudes, Confidence, and Knowledge Scale for Assessing Metabolic Health" (M-Back-Tr) to determine the barriers, attitudes, confidence, and knowledge status of psychiatry professionals in the assessing of metabolic syndrome.

METHODS

This methodological study was conducted with 304 psychiatric nurses who were working in public and private healthcare institutions between March and June 2023. Translation and back-translation were made into the Turkish language during the adaptation process and it was found that there was no semantic shift between the versions. While the validity of M-Back-Tr was tested with content validity, construct validity, and convergent validity, its internal reliability and Split-Half Test Reliability were examined for reliability.

RESULTS

The structure of M-Back-Tr, which consists of 4 dimensions (i.e., Barriers, Attitudes, Confidence, Knowledge) and 16 items, was confirmed in Turkish culture. This structure can explain 73 % of the variance in the related concept. The minimum score that can be taken from each sub-dimension is 4 and the maximum is 20. The Cronbach α value of the sub-dimensions of the scale was found to be between 0.79 and 0.91.

CONCLUSION

The study findings showed that the M-Back-Tr is a valid and reliable measurement tool that can be used in Turkish culture.

Effectiveness of lifestyle intervention on prevention/management of antipsychotic-induced weight gain among persons with severe mental illness: A systematic review and meta-analysis

Individualized lifestyle interventions using motivational interviewing (MI) approach are recommended for persons with severe mental illness (SMI) for effective weight management. The aim of this meta-analysis was to assess the effectiveness of various lifestyle interventions that addressed obesity among persons with SMI. Twelve RCTs were assessed by individual reviewers using revised cochrane risk-of-bias tool (RoB 2). The standardized mean difference (SMD) was calculated with a 95% CI. The age of participants was between 18 and 70 years. Waist circumference showed an SMD of -0.09 (-0.22, 0.03), weight -0.03 (-0.10, 0.15) and BMI -0.07 (-0.07, 0.22). The findings in this meta-analysis revealed that though lifestyle interventions were statistically insignificant in reducing antipsychotic induced weight gain among persons with SMI, they show changes in intervention group. Psychosocial management along with lifestyle interventions, and MI are effective in the management of antipsychotic induced weight gain.

Safety and Effect of Bariatric Metabolic Surgeries for Psychiatric Patients with Obesity: A Retrospective Matched Case-control Trial

INTRODUCTION

Patients living with psychiatric illnesses (PIs) have a high prevalence of obesity. In a 2006 survey, 91.2% of professionals in the bariatric field identified "psychiatric issues" as clear contraindications to weight-loss surgery.

METHODS

This retrospective matched case-control study investigated the impact, safety, and possible relapse after bariatric metabolic surgery (BMS) in patients with PIs. Also, we tested the incidence of patients who developed PI after BMS and compared the post-procedural weight loss with that in a matched control group without PIs. The cases were matched in a ratio of 1:4 to the control patients standardized for age, sex, preoperative BMI, and type of BMS.

RESULTS

Of 5987 patients, 2.82% had a preoperative PI; postoperative de novo PI was present in 0.45%. Postoperative BMI was significantly different between the groups when compared to preoperative BMI (p < 0.001). Percentage of total weight loss (%TWL) after six months was not significantly different between the case (24.6% ± 8.9) and control groups (24.0% ± 8.4, p = 1.000). Early and late complications were not significantly different between the groups. The psychiatric drug use and dosage changes did not differ significantly pre- and postoperatively. Of the psychiatric patients, 5.1% were postoperatively admitted to a psychiatric hospital (p = 0.06) unrelated to BMS, and 3.4% had a prolonged absence from work after surgery.

CONCLUSION

BMS is an effective weight loss treatment and a safe procedure for patients with psychiatric disorders. We found no change in the patients' psychiatric status outside the usual disease course. Postoperative de novo PI was rare in the present study. Furthermore, patients with severe psychiatric illness were excluded from undergoing surgery and, therefore, from the study. Careful follow-up is necessary to guide and protect patients with PI.

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.

Risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 mortality in people with pre-existing mental disorders: an umbrella review

INTRODUCTION

The COVID-19 pandemic has posed a serious health risk, especially in vulnerable populations. Even before the pandemic, people with mental disorders had worse physical health outcomes compared to the general population. This umbrella review investigated whether having a pre-pandemic mental disorder was associated with worse physical health outcomes due to the COVID-19 pandemic.

METHODS

Following a pre-registered protocol available on the Open Science Framework platform, we searched Ovid MEDLINE All, Embase (Ovid), PsycINFO (Ovid), CINAHL, and Web of Science up to the 6th of October 2021 for systematic reviews on the impact of COVID-19 on people with pre-existing mental disorders. The following outcomes were considered: risk of contracting the SARS-CoV-2 infection, risk of severe illness, COVID-19 related mortality risk, risk of long-term physical symptoms after COVID-19. For meta-analyses, we considered adjusted odds ratio (OR) as effect size measure. Screening, data extraction and quality assessment with the AMSTAR 2 tool have been done in parallel and duplicate.

RESULTS

We included five meta-analyses and four narrative reviews. The meta-analyses reported that people with any mental disorder had an increased risk of SARS-CoV-2 infection (OR: 1.71, 95% CI 1.09-2.69), severe illness course (OR from 1.32 to 1.77, 95%CI between 1.19-1.46 and 1.29-2.42, respectively) and COVID-19 related mortality (OR from 1.38 to 1.52, 95%CI between 1.15-1.65 and 1.20-1.93, respectively) as compared to the general population. People with anxiety disorders had an increased risk of SAR-CoV-2 infection, but not increased mortality. People with mood and schizophrenia spectrum disorders had an increased COVID-19 related mortality but without evidence of increased risk of severe COVID-19 illness. Narrative reviews were consistent with findings from the meta-analyses.

DISCUSSION AND CONCLUSIONS

As compared to the general population, there is strong evidence showing that people with pre-existing mental disorders suffered from worse physical health outcomes due to the COVID-19 pandemic and may therefore be considered a risk group similar to people with underlying physical conditions. Factors likely involved include living accommodations with barriers to social distancing, cardiovascular comorbidities, psychotropic medications and difficulties in accessing high-intensity medical care.

Psychiatric Disorders and Obesity in Childhood and Adolescence-A Systematic Review of Cross-Sectional Studies

Obesity and psychiatric disorders have high prevalence and are both considered major health problems. Within the last decades, the rates of obesity have risen over 6%, while the prevalence of psychiatric disorders is over 12% for children and adolescents. The aim of this study was to systematically review the evidence regarding the relation of obesity and psychiatric disorders in childhood and adolescence. This review, based on the PRISMA guidelines, included cross-sectional studies published within the last decade, pertaining to the relation between psychiatric disorders and obesity in children and adolescents up to the age of 19 years. Studies on eating disorders were excluded. A total of 14 studies of 23,442 children and adolescents that investigated the relation of obesity with anxiety, mood disorders, and psychosis were included in this systematic review. Nine of the included studies reported a significant relationship between the psychiatric disorder under investigation and obesity. Understanding the nexus between obesity and psychiatric disorders in children and adolescents is of great importance, given the alarming increase in both conditions in youth. Such findings could facilitate the development and implementation of targeted interventions.

Health status of young adults with serious mental illness enrolled in integrated care

AIMS

People with serious mental illness (SMI) are more likely to develop chronic health conditions and die prematurely. Timely identification of modifiable health risk factors may enable early intervention. We aimed to describe the physical health characteristics and service utilization of young people with SMI.

METHODS

Young people with SMI enrolled in an integrated community mental health clinic (CMHC) and primary care program were assessed for physical and mental health history and past year service utilization.

RESULTS

A total of 122 participants, ages 16-35 (m = 27.0 ± 5.0 years), half male, 78.3% White were assessed. Half smoked cigarettes, half had obesity, almost half (47.5%, n = 56) had hypertension, and about a third had laboratory metabolic abnormalities. The group averaged 10.7 ± 5.1 h of sedentary behavior per day. Obesity was associated with high blood pressure, prediabetes, poor self-rated health abilities, sedentary behavior and low health satisfaction. Over half had been to the emergency department (ED) for a medical reason (55.0%, n = 66) and 24.6% had been hospitalized for a health condition in the past year. Over half had a lifetime cardiovascular risk score indicating a 50-67% chance of having a cardiovascular event; simply quitting smoking would reduce the number with this risk by almost half. Most physical health diagnoses were not recorded in the CMHC record.

CONCLUSION

Young people with SMI newly enrolled in integrated care had high rates of smoking, obesity, hypertension, and other cardio-metabolic abnormalities contributing to high risk for future disease. Research is needed to examine appealing, scalable interventions to improve health, reduce unnecessary medical care, and prevent disparate chronic disease in this group.

Factors associated with weight gain prevention in young adults with serious mental illness

AIM

The purpose of this study was to examine factors associated with weight gain prevention among young adults with serious mental illness who participated in the Fit Forward randomized controlled trial evaluating lifestyle interventions adapted for this high-risk group. The aims were to: (1) examine baseline differences between participants that gained weight and those that lost or maintained weight at six and 12 months, and (2) evaluate whether changes in weight control strategies were associated with weight gain prevention at 6 and 12 months.

METHODS

This study was a secondary analysis of the Fit Forward Study. Participants were young adults (age 18-35) with a serious mental illness and a body mass index in the overweight or obese range. Participants completed assessments at baseline and 6 and 12 months. t-Tests and chi-squared tests were used to examine baseline differences between those that gained weight and those that lost/maintained weight. Logistic regression was used to evaluate whether changes in weight control strategies were associated with weight gain prevention in the sample overall.

RESULTS

Lower baseline BMI was significantly associated with weight gain prevention at six and 12 months. Greater increases in weight control strategies total score and psychological coping subscale were significantly associated with weight gain prevention at six and 12 months.

CONCLUSIONS

Weight control strategies, particularly psychological coping tools that support positive thinking and reduce negative self-talk should be considered as core strategies in healthy lifestyle interventions aimed at preventing weight gain in young adults with serious mental illness.

Obesity and brain structure in schizophrenia - ENIGMA study in 3021 individuals

Schizophrenia is frequently associated with obesity, which is linked with neurostructural alterations. Yet, we do not understand how the brain correlates of obesity map onto the brain changes in schizophrenia. We obtained MRI-derived brain cortical and subcortical measures and body mass index (BMI) from 1260 individuals with schizophrenia and 1761 controls from 12 independent research sites within the ENIGMA-Schizophrenia Working Group. We jointly modeled the statistical effects of schizophrenia and BMI using mixed effects. BMI was additively associated with structure of many of the same brain regions as schizophrenia, but the cortical and subcortical alterations in schizophrenia were more widespread and pronounced. Both BMI and schizophrenia were primarily associated with changes in cortical thickness, with fewer correlates in surface area. While, BMI was negatively associated with cortical thickness, the significant associations between BMI and surface area or subcortical volumes were positive. Lastly, the brain correlates of obesity were replicated among large studies and closely resembled neurostructural changes in major depressive disorders. We confirmed widespread associations between BMI and brain structure in individuals with schizophrenia. People with both obesity and schizophrenia showed more pronounced brain alterations than people with only one of these conditions. Obesity appears to be a relevant factor which could account for heterogeneity of brain imaging findings and for differences in brain imaging outcomes among people with schizophrenia.

The Effects of Use of Long-Term Second-Generation Antipsychotics on Liver and Kidney Function: A Prospective Study

(1) Background: The second-generation antipsychotics (SGAPs) induce metabolic and inflammatory side effects, but documentation of their effects on the liver and kidneys is scarce. Aim: To study the three-year fluctuation of selected markers of renal and hepatic function in forensic psychiatric patients receiving SGAPs for more than five years. (2) Methods: Thirty-five forensic psychiatric patients (N = 35) were classified into two groups according to the type of SGAPs used for their treatment and the relevant risk of weight gain and metabolic complications. The three-year medication history, anthropometric data and biochemical data relevant to renal and hepatic function were retrieved from the individual medical files, specifically: serum levels of urea, uric acid, creatinine, alkaline phosphatase and amylase; the liver function enzymes, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and gamma-glutamyl transpeptidase(γ-GT), and also the inflammatory index C-reactive protein (CRP). (3) Results: The patients receiving the SGAPs with a low risk for weight gain showed no significant fluctuation in the biochemical markers over the three-year period. The patients receiving the SGAPs with a high risk for weight gain showed significant differences between at least two measurements of uric acid (p = 0.015), SGOT (p = 0.018) and SGPT (p = 0.051). They showed significantly higher levels of creatinine in the third year compared to the second year (p = 0.029), and SGOT in the second year compared to the first (p = 0.038), and lower levels of SGPT in the third year compared to the second (p = 0.024). (4) Conclusion:In addition to consideration of possible metabolic and inflammatory complications, the choice of an antipsychotic drug for long-term treatment should also take into account the risk of hepatotoxicity and kidney damage.

Oral administration of processed Cassia obtusifolia L. seed powder May reduce body weight and cholesterol in overweight patients with schizophrenia: A 36-week randomized, double-blind, controlled trial of high and low doses

ETHNOPHARMACOLOGICAL RELEVANCE

Obesity in patients with schizophrenia is related to antipsychotic drug use, hypertension, diabetes, and dyslipidemia, which are critical risk factors for cardiovascular disease. Cassia seed is a traditional Chinese medicine that can be used to treat various eye disorders. Anthraquinone-containing Cassia seed were used to lower serum levels of fat and cholesterol.

AIM OF STUDY

The effects of Cassia seed powder on body weight and lipids were investigated in overweight or obese patients with schizophrenia.

METHODS

The present study was designed as a double-blind, randomized, controlled trial. Ninety-four patients with schizophrenia who were overweight or obese were assigned to a control group (CG, 47 patients) and treatment group (TG, 47 patients) that received low dose Cassia seed power (0.3 g once daily) and Cassia seed powder (3.0 g once daily), respectively, for 36 weeks. The main outcome was the change in body mass index and waist circumference (WC). The secondary outcome was the change in serum lipids, C-reactive protein, interleukin-6, and glycated hemoglobin.

RESULTS

Seventy-four patients completed the study (n = 36, CG; n = 38, TG). WC was significantly lower at the second (24 weeks, 98.63 ± 9.44 vs 95.80 ± 10.26 cm, p = 0.023), third (36 weeks, 98.35 ± 9.46 vs 95.05 ± 10.07 cm, p = 0.002), and fourth (48 weeks, 98.78 ± 9.48 vs 93.73 ± 10.28 cm, p < 0.001) follow-ups than at baseline in the TG, but only significantly lower than baseline at the fourth follow-up (100.78 ± 13.98 vs 94.03 ± 9.74 cm, p = 0.006); no significant difference in CG was observed at both the second (101.03 ± 13.62 vs 97.35 ± 8,29 cm, p = 0.08) and third (100.55 ± 13.69 vs 96.55 ± 8.29 cm, p = 0.066) follow-up. The difference in serum total cholesterol and low-density lipoprotein levels between the baseline and the third follow-up was greater in the TG than in the CG (149.68 ± 34.85 vs 179.08 ± 75.87 mg/dL, p = 0.033; 84.40 ± 28.06 vs102.08 ± 34.12 mg/dL, p = 0.015, respectively).

CONCLUSION

In patients with schizophrenia who were overweight or obese, oral administration of Cassia seed powder (3.0 g) for 24 weeks and 36 weeks reduced WC, and oral administration of Cassia seed powder for 36 weeks reduced total cholesterol and low-density lipoprotein levels, suggesting that Cassia seed powder aids the management of patients with schizophrenia who are overweight or obese. However, these results are preliminary, and future studies should use larger sample sizes, multiple testing centers, and multiple dosing.

Investigating Body Mass Index and Body Composition in Patients with Schizophrenia: A Case-Control Study

BACKGROUND

Antipsychotics exert metabolic side effects, and prolonged treatment with antipsychotics causes changes in body weight and muscle composition. Nevertheless, reports on the changes in body composition of patients with schizophrenia have been limited. This study is aimed at comparing the body mass index and body composition of patients with schizophrenia with healthy individuals in Indonesia.

METHODS

A total of 195 patients with schizophrenia (148 males and 47 females) and 195 healthy individuals matched by gender were recruited. Using the Bioelectrical Impedance Analysis method, the participants' body compositions were measured.

RESULTS

Compared to healthy individuals, the patient group exhibited a higher rate of underweight as well as a lower rate of overweight and obesity. Multiple regression analysis confirmed the associations between the body mass index and all measured body compositions. Furthermore, the diagnosis of schizophrenia is significantly associated with lower muscle mass, lower bone mass, higher basal metabolic rate, older metabolic age, and higher total body water.

CONCLUSIONS

The results showed that patients with schizophrenia are at a greater risk of a lower quality of certain components of body composition. Priority should be given to research that addresses increasing the patient's level of physical activity.

Impact of exergames on psychiatric symptoms in older adults with serious mental illness

OBJECTIVES

Older adults with serious mental illness (SMI) are more likely to have high body mass index (BMI) and chronic conditions such as cardiovascular disease and diabetes. A sedentary lifestyle, which may be attributed to pharmacologic side effects and the symptoms of mental illness, has been difficult to treat. Patients experiencing negative symptoms (e.g. apathy, anhedonia) may be more likely to exercise in a group setting with activities that are designed to stimulate the mind and encourage engagement. "Exergames," or exercise-based videogames, are an interactive and stimulating method to provide aerobic activities. Exercise has also been shown to reduce the symptoms of depression. The purpose of this study is to evaluate the impact of a 10-week exergame program on depressive and negative symptoms in older adults with SMI.

MATERIALS AND METHODS

A single-group pretest posttest study was conducted with 52 older adults diagnosed with SMI. Participants engaged in group exergame activities for 50-minute sessions three times a week for 10 weeks. The Patient Reported Outcome Measurement Information System (PROMIS) and the Scale for the Assessment of Negative Symptoms (SANS) were conducted at enrollment, 5 weeks, and 10 weeks.

RESULTS

Participants achieved statistically significant reductions in self-reported depressive symptoms (-0.83, LL -1.46, UL -0.12) and observed negative symptoms (-5.29, LL -7.67, UL -3.14) over a 10-week period.

CONCLUSIONS

Our results suggest utilization of exergames as an adjunct treatment can be an effective, engaging, and cost-efficient method to reducing depressive and negative symptoms in older adults with SMI.

Impact of elevated BMI and types of comorbid conditions on health-related quality of life in a nationally representative US sample

OBJECTIVE

Elevated BMI is associated with multiple chronic conditions including diabetes and CVD. Patients with overweight or obesity may also suffer from comorbidities not directly related to the pathophysiology of elevated BMI. The current study sought to determine the impact of BMI and different types of chronic conditions on health-related quality of life (HRQoL) outcomes.

DESIGN

Six weight categories by BMI were identified: underweight, normal weight, overweight, Class-I obesity, Class-II obesity and Class-III obesity. Twenty chronic conditions were considered and categorised as elevated BMI-related (concordant) or -unrelated (discordant) conditions. HRQoL outcomes were measured using Short Form-6 Dimensions (SF-6D). Multivariable regression models were performed to examine the impact of type, number of comorbid conditions and BMI categories on SF-6D scores.

SETTING

Medical Expenditure Panel Survey (2013-2015).

PARTICIPANTS

Nationally representative sample of US population; 18 years or older (n 58 960).

RESULTS

Of the sample, 1·7 %, 32·9 %, 34·0 % and 31·4 % were classified as underweight, normal weight, overweight and obese, respectively. The SF-6D scores were significantly decreased across all obesity classes, with the largest reduction in Class-III obesity (0·033; P < 0·001). Additionally, individuals with obesity having one or more concordant or discordant comorbidities further reduced SF-6D scores between 0·031 and 0·148 (P-values < 0·001) or between 0·080 and 0·212 (P-values < 0·001), respectively.

CONCLUSIONS

Individuals with obesity had a significant reduction in HRQoL outcomes compared to those with normal BMI. Importantly, discordant comorbidity resulted in greater reduction in HRQoL outcomes compared to concordant comorbidity in subjects with elevated BMI.

Obesity and Mental Health: A Longitudinal, Cross-Cultural Examination in Germany and China

The present study examines the relationship between obesity and mental health using longitudinal data. Participants with data at baseline and one-year follow-up were included from two countries: Germany (364) and China (9007). A series of structural equation models with three mediators and one moderator were conducted separately for female and male students in Germany and China. Zero-order correlations indicated that overweight/obesity was significantly related to later depression and anxiety in Chinese males. Additional effects of obesity on later mental health flowed through effects on attractiveness (Chinese and German females, and Chinese males), physical health (Chinese males), and life satisfaction (German females). Though overweight/obesity is related to mental health across many other studies, results in this study yield total effects between overweight/obesity and follow-up mental health only in Chinese males. The relationship between overweight/obesity and follow-up mental health was significantly mediated by follow-up attractiveness, or health state, or life satisfaction in German females, Chinese females, and Chinese male students, with no significant indirect effects found in German male students. This highlights the possible importance of culture in examining these effects.

Obstetric near misses among women with serious mental illness: data linkage cohort study

BACKGROUND

Investigating obstetric near misses (life-threatening obstetric complications) provides crucial information to prevent maternal mortality and morbidity.

AIMS

To investigate the rate and type of obstetric near misses among women with serious mental illness (SMI).

METHOD

We conducted a historical cohort study, using de-identified electronic mental health records linked with maternity data from Hospital Episode Statistics. The English Maternal Morbidity Outcome Indicator was used to identify obstetric near misses at the time of delivery in two cohorts: (1) exposed cohort - all women with a live or still birth in 2007-2016, and a history of secondary mental healthcare before delivery in south-east London (n = 13 570); (2) unexposed cohort - all women with a live or still birth in 2007-2016, resident within south-east London, with no history of mental healthcare before delivery (n = 223 274).

RESULTS

The rate of obstetric near misses was 884.3/100 000 (95% CI 733.2-1057.4) maternities in the exposed group compared with 575.1/100 000 (95% CI 544.0-607.4) maternities in the unexposed group (adjusted odds ratio 1.6, 95% CI 1.3-2.0, P < 0.001). Highest risks were for acute renal failure (adjusted odds ratio 2.1, 95% CI 1.1-3.8, P = 0.022); cardiac arrest, failure or infarction (adjusted odds ratio 2.3, 95% CI 1.1-4.8, P = 0.028); and obstetric embolism (adjusted odds ratio 3.1, 95% CI 1.6-5.8, P < 0.001).

CONCLUSIONS

Findings emphasise the importance of integrated physical and mental healthcare before and during pregnancy for women with SMI.

Profile of recipients of holistic health counselling in a psychiatric OPD in South India

BACKGROUND OF THE STUDY

Persons with mental illness (PwMI) are prone to weight gain as a side effect of antipsychotics. Health counselling on diet, physical activity, medication adherence, expressed emotions and technology use, by health professionals, can help in managing these side-effects.

AIM

The aim of this study was to identify the pre-counselling profile of the subjects such as body mass index (BMI), diet, physical activity, medication adherence, expressed emotions and technology use among PwMI; to attend the Holistic Health Clinic as part of follow-up services in the psychiatry Outpatient Department (OPD) as well as to find correlation and association between the study variables.

METHODS

The study involved a cross-sectional descriptive design based on convenience sampling. The sample consists of 56 patients who are receiving antipsychotics under symptom control (self-reported) and were overweight. Data were collected with a patient assessment proforma and analysed using SPSS-22.

RESULTS

The patients referred to the holistic health counselling (HHC) had abnormal weight and BMI. The mean and SD of weight was 74.48 ± 14.07 and BMI 29.51 ± 5.15. All the participants received counselling on diet, 87.5% on physical activity, 62.5% on sleep hygiene, 55.4% on medication adherence, 8.9% on family emotional climate and only 5.4% on healthy use of technology. Weight has shown significant relation with gender (male = 80.84 ± 17.71, female = 71.09 ± 10.52, t = -2.52, p = .015) and near to significant relationship (χ² = 7.685, p = .053) with educational status.

CONCLUSION

Patients receiving second-generation antipsychotics (SGA) have lesser extra pyramidal side-effects; however, they are more prone to gain weight. Proper screening and counselling during the follow-up visit in the outpatient setting can help in identification, prevention and management of the obesity-related metabolic syndrome and cardiovascular disease (CVD), and motivate them to adopt healthy behaviours.

An Innovative Approach to Designing Digital Health Solutions Addressing the Unmet Needs of Obese Patients in Europe

According to the World Health Organization (WHO), the worldwide obesity rate has tripled since 1975. In Europe, more than half of the population is overweight and obese. Around 2.8 million people die each year worldwide as a result of conditions linked to being overweight or obese. This study aimed to analyze the policies, approaches, and solutions that address the social and health unmet needs of obese patients, at different levels, in order to simulate the definition of an integrated approach, and to provide and share examples of innovative solutions supporting health promotion, disease prevention, and integration of services to improve the collaboration between the different health and care stakeholders involved across the country and in the lives of obese patients. A collaborative approach involving various levels of government and regional experts from different European countries was applied to identify, explore, and evaluate different aspects of the topic, from the innovation perspective and focusing on a European and a regional vision. Currently, people prefer more foods rich in fats, sugars, and salt/sodium than fruits, vegetables, and fiber. This behavior leads to a significant negative impact on their health-related quality of life. Changes in healthcare systems, healthy policy, and approaches to patient care and better implementation of the different prevention strategies between all the stakeholders are needed, taking advantage of the digital transformation of health and care. Such changes can support obese patients in their fight against an unhealthy lifestyle and at the same time reduce healthcare costs.

Determining Predictors of Weight Loss in a Behavioral Intervention: A Case Study in the Use of Lasso Regression

OBJECTIVE

This study investigates predictors of weight loss among individuals with serious mental illness participating in an 18-month behavioral weight loss intervention, using Lasso regression to select the most powerful predictors.

METHODS

Data were analyzed from the intervention group of the ACHIEVE trial, an 18-month behavioral weight loss intervention in adults with serious mental illness. Lasso regression was employed to identify predictors of at least five-pound weight loss across the intervention time span. Once predictors were identified, classification trees were created to show examples of how to classify participants into having likely outcomes based on characteristics at baseline and during the intervention.

RESULTS

The analyzed sample contained 137 participants. Seventy-one (51.8%) individuals had a net weight loss of at least five pounds from baseline to 18 months. The Lasso regression selected weight loss from baseline to 6 months as a primary predictor of at least five pound 18-month weight loss, with a standardized coefficient of 0.51 (95% CI: -0.37, 1.40). Three other variables were also selected in the regression but added minimal predictive ability.

CONCLUSIONS

The analyses in this paper demonstrate the importance of tracking weight loss incrementally during an intervention as an indicator for overall weight loss, as well as the challenges in predicting long-term weight loss with other variables commonly available in clinical trials. The methods used in this paper also exemplify how to effectively analyze a clinical trial dataset containing many variables and identify factors related to desired outcomes.

The Acceptability and Feasibility of Using Text Messaging to Support the Delivery of Physical Health Care in those Suffering from a Psychotic Disorder: a Review of the Literature

Those suffering with serious mental illness (SMI), such as psychotic disorders, experience life expectancy 15 years shorter than the general population. Cardiovascular disease is the biggest cause of death in those with psychotic disease and many risk factors may be limited by healthy lifestyle choices. Text messaging interventions represent mobile health (mHealth), a nascent way to deliver physical health care to those suffering with a psychotic disorder. This paper aims to review the literature on the feasibility of text messaging to support the delivery of physical health care in those with a psychotic disorder. A thorough electronic database literature review of Medline via Ovid, Embase, APA Psycinfo, Scopus, Cochrane and Web of Science was conducted. Articles were included if text messaging was used as an intervention targeting the physical health of patients with psychotic disorders. A final sample of 11 articles satisfied the eligibility criteria, of which, 3 were ongoing randomised controlled trials. Of the 8 completed trials, all demonstrated the promising feasibility of text messaging, assessed via quotes, conversation samples, response rates, questionnaires or directly based on physical results. 36% of studies analysed those with schizophrenia or schizoaffective disorder, 55% with SMI and 9% with schizophrenia and psychotic disorders, mood disorders or anxiety disorders. Text messaging was used as motivation or reminders (91%), service delivery (27%) or social support (27%) with studies targeting multiple themes simultaneously. This review highlights compelling evidence for the feasibility of text messaging for improvement of physical health in those suffering with psychotic disorders.

Real-Time Data Collection to Examine Relations Between Physical Activity and Affect in Adults With Mental Illness

Adults with serious mental illness engage in limited physical activity, which contributes to significant health disparities. This study explored the use of both ecological momentary assessments (EMAs) and activity trackers in adults with serious mental illness to examine the bidirectional relationship between activity and affect with multilevel modeling. Affective states were assessed up to seven times per day using EMA across 4 days. The participants (n = 20) were equipped with a waist-worn accelerometer to measure moderate to vigorous physical activity. The participants had a mean EMA compliance rate of 88.3%, and over 90% of completed EMAs were matched with 30-min windows of accelerometer wear. The participants who reported more positive affect than others had a higher probability of engaging in moderate to vigorous physical activity. Engaging in more moderate to vigorous physical activity than one's usual was associated with more negative affect. This study begins to address the effect of momentary mood on physical activity in a population of adults that is typically difficult to reach.

PTSD and obesity in U.S. military veterans: Prevalence, health burden, and suicidality

Post-traumatic stress disorder (PTSD) and obesity are prevalent among U.S. military veterans, though less is known about the mental and physical health burden and suicidality of co-occurring PTSD and obesity in this population. A nationally representative sample of the U.S. veterans was used to assess PTSD and obesity prevalence, co-occurrence and relationships with mental and physical health measures. A total of 16.4% of veterans screened positive for current PTSD, 32.7% for obesity, and 5.8% for co-occurring PTSD and obesity. Relative to obesity-only veterans, veterans with co-occurring PTSD and obesity had elevated likelihoods of mental and physical health concerns (most notably major depressive and generalized anxiety disorders), suicidality, and migraine headaches, and higher body mass indices. Relative to veterans with PTSD alone, individuals with comorbid PTSD and obesity had elevated likelihoods of suicidal ideation, nicotine dependence, mental health treatment, migraine headaches, diabetes, hypertension, and insomnia. A significant minority of U.S. veterans has co-occurring PTSD and obesity, which is associated with substantial mental and physical health burden, including elevated suicidality.  Results underscore the importance of integrative assessment, monitoring, and treatment approaches for PTSD and obesity in this population.

Body mass index, residual psychotic symptoms, and inflammation associated with brain volume reduction in older patients with schizophrenia

Obesity, aging, and pathophysiology of schizophrenia (SCZ) may collectively contribute to the gray matter loss in brain regions of SCZ. We attempted to examine the association between volumes of specific brain regions, body mass index (BMI), inflammatory markers, and clinical features in older SCZ patients.

METHOD

Clinically stable outpatients with schizophrenia (DSM-IV) aged ≥50 years were recruited to undergo whole-brain magnetic resonance imaging. We measured patients' plasma levels of soluble tumor necrosis factor receptor-1, soluble interleukin (IL)-2 receptor (sIL-2R), IL-1β, and IL-1 receptor antagonist (IL-1Ra). Clinical data were obtained from medical records and interviewing patients along with their reliable others.

RESULTS

There were 32 patients with mean age 58.8 years in this study. Multivariate regression analysis found only higher BMI significantly associated with lower volume of total gray matter, bilateral orbitofrontal and prefrontal cortexes, and the right hippocampal and frontal cortexes. Increased intensity of residual symptoms (higher Positive and Negative Syndrome Scale scores) was related to lower volumes of frontal lobe, prefrontal cortex, insula, hippocampus, left hemisphere amygdala, and total white matter. The lower volume of left anterior cingulum was associated with older age and higher sIL-2R plasma level; and higher IL-1Ra level was associated with greater right anterior cingulate volume. Older age at illness onset was significantly associated with the smaller right insula volume.

CONCLUSIONS

Higher BMI, more residual symptoms, and inflammatory activity in IL-2 and IL-1 systems may play a role in gray matter loss in various brain regions of schizophrenia across the life span.

Impact of male-only lifestyle interventions on men's mental health: A systematic review and meta-analysis

Despite rising mental health problems worldwide, engaging men to seek mental health support is challenging. Male-only lifestyle interventions have shown promise for improving men's physical health, but the overall impact of these programs on psychological outcomes is unclear. This review aimed to evaluate the impact of male-only lifestyle interventions on men's mental health and to identify if any study or intervention features were associated with effectiveness. A systematic literature search with no date restrictions was conducted across four databases and returned 15 946 citations. Nine studies were eligible for inclusion, representing 1427 participants. Risk of bias was generally low across studies, although none were specifically powered to detect changes in mental health. Overall, significant group-by-time effects were reported for 26% of mental health outcomes examined. In the fixed-effects meta-analyses, small-to-medium intervention effects were observed for mental health-related quality of life (SMD = 0.24), self-esteem (SMD = 0.51), and positive affect (SMD = 0.58). Insights into effective study or intervention features were limited because of the low number of heterogeneous studies. Although male-only lifestyle interventions have improved men's mental health in some circumstances, studies that are specifically powered to detect long-term changes are urgently required, particularly in groups with pre-existing mental health concerns.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Experiences of Weight-Loss Surgery in People With Serious Mental Illness: A Qualitative Study

BACKGROUND

Bariatric surgery is seldom accessed by people with serious mental illness, despite high rates of obesity in this population. It is sometimes assumed that patients with complex psychiatric histories will have poor post-surgical weight loss or exacerbation of psychiatric symptoms, although this is unsubstantiated.

OBJECTIVES

A qualitative descriptive study to explore personal experiences and the impact of bariatric surgery on physical and mental well-being and life-quality in individuals with serious mental illness.

METHODS

Nine adults with a history of bariatric surgery and concurrent severe depressive disorder, bipolar disorder, or schizoaffective disorder were interviewed about their experiences of bariatric surgery and its outcomes using semi-structured interview schedules. Data were transcribed and inductive thematic analysis undertaken.

RESULTS

Five broad themes emerged: (1) surgery was highly effective for weight loss, and resulted in subjective improvements in physical health, quality of life, and mental health described as being able to live a life; (2) recovering from surgery was a tough road, notably in the post-operative period where negative sequelae often anteceded benefits; (3) post-operative support was important, but sometimes insufficient, including from families, mental health services, and surgical teams; (4) most considered surgery life-changing, recommending it to others with mental illness and obesity, two had different experiences; (5) participants considered it discriminatory that people with mental illness were not referred or declined weight loss surgery.

CONCLUSIONS

Participants benefited from bariatric surgery and felt it should be offered to others with mental illness, but with additional care and support.

Deficits in Sexual Interest Among Adults With Schizophrenia: Another Look at an Old Problem

OBJECTIVE

Despite the important impact of sexuality on quality of life in adults, there is a paucity of research on this topic for people with schizophrenia. This study examined predictors of sexual interest among adults with schizophrenia.

METHODS

Using data from three studies with similar measures and participants with similar characteristics (N=231), the authors conducted a secondary analysis to examine the relationships among sexual interest, demographic characteristics (gender, age, living situation, and marital status), and clinical factors (sexual self-efficacy, symptom severity, and medications). Sexual interest was measured by using one item from the Scale to Assess Negative Symptoms. Binomial logistic regressions were conducted to explore factors most associated with level of sexual interest.

RESULTS

Separately, cardiovascular medications, gender, age, sexual self-efficacy, and negative symptoms were associated with sexual interest. In a logistic regression model that included all of these factors, only sexual self-efficacy and gender were significantly associated with sexual interest. Higher levels of sexual self-efficacy were associated with lower levels of impairment in sexual interest (odds ratio [OR]=0.98, 95% confidence interval [CI]=0.98-0.99, p<0.001), and males were less likely than females to have impaired sexual interest (OR=0.38, 95% CI=0.20-0.73, p=0.004).

CONCLUSIONS

The strength of the relationship between sexual self-efficacy and sexual interest warrants development of interventions to address sexuality among people with serious mental illness, at least for those who are interested in developing or maintaining intimate relationships. An intervention that teaches skills needed to successfully pursue and navigate intimate relationships could positively influence overall quality of life for many.

Incentivizing healthy lifestyle behaviors to reduce cardiovascular risk in people with serious mental illness: An equipoise randomized controlled trial of the wellness incentives program

BACKGROUND

Medicaid recipients with serious mental illness die 25-30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers).

METHODS

Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months.

DISCUSSION

New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation.

Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental Illness

INTRODUCTION

US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers.

METHODS

Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression.

RESULTS

A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20-5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit.

CONCLUSIONS

Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI.

Perspectives on diet and physical activity among urban African Americans with serious mental illness

African Americans are burdened by high rates of obesity that contribute to chronic disease and early mortality. To tailor a weight loss intervention to meet the needs of African Americans with serious mental illness, a community-based participatory research (CBPR) team comprised primarily of African Americans with serious mental illness guided qualitative research to understand factors that affect weight and interventions that may diminish obesity. Data from five focus groups (n = 55) were analyzed to better understand this group's needs. Participants voiced individual, social, and structural barriers to maintaining and achieving a healthy weight and provided perspectives on potential solutions.

Enhanced anxiety-like behavior emerges with weight gain in male and female obesity-susceptible rats

Epidemiological data suggest that body mass index and obesity are strong risk factors for depression and anxiety. However, it is difficult to separate cause from effect, as predisposition to obesity may enhance susceptibility to anxiety, or vice versa. Here, we examined the effect of diet and obesity on anxiety-like behaviors in male and female selectively bred obesity-prone and obesity-resistant rats, and outbred Sprague-Dawley rats. We found that when obesity-prone and obesity-resistant rats do not differ in weight or fat mass, measures of anxiety-like behavior in the elevated plus maze and open field are similar between the two groups. However, once weight and fat mass diverge, group differences emerge, with greater anxiety in obesity-prone relative to obesity-resistant rats. This same pattern was observed for males and females. Interestingly, even when obesity-resistant rats were "forced" to gain fat mass comparable to obesity-prone rats (via prolonged access to 60% high-fat diet), anxiety-like behaviors did not differ from lean chow fed controls. In addition, a positive correlation between anxiety-like behaviors and adiposity were observed in male but not in female obesity-prone rats. Finally, diet-induced weight gain in and of itself was not sufficient to increase measures of anxiety in outbred male rats. Together, these data suggest that interactions between susceptibility to obesity and physiological alterations accompanying weight gain may contribute to the development of enhanced anxiety.

Patient perspectives on how living with a mental illness affects making and maintaining healthy lifestyle changes

OBJECTIVE

To understand the ways that mental health symptoms interfere with achieving health goals.

METHODS

Individuals with mental illness diagnoses and varying levels of preventive service use were recruited from federally qualified health centers and an integrated health care delivery system and interviewed. Thematic analysis was used to characterize descriptions of how mental illness experiences influenced lifestyle change efforts.

RESULTS

Three themes described patients' (n = 163) perspectives on barriers to making healthy lifestyle changes: 1) Thinking about making lifestyle changes is overwhelming for individuals already managing the burdens of mental illnesses; 2) Depression makes it difficult to care about a healthy future; and 3) When mental illness symptoms are not adequately treated unhealthy behaviors that provide relief are unlikely to be discontinued. Participants also made suggestions for improving health care delivery to facilitate positive behavior change.

CONCLUSION

Patients with mental illnesses need their clinicians to be empathic, help them envision a healthier future, address unmet mental health needs, and provide resources.

PRACTICE IMPLICATIONS

Primary care clinicians should encourage their patients with mental illnesses to make healthy lifestyle changes within the context of a supportive relationship. Lifestyle change can be overwhelming; clinicians should acknowledge progress and provide ongoing tangible support.

Contemporary approaches in mental health rehabilitation

In many European countries, deinstitutionalisation has been an ongoing process over the last few decades. Mental health organisations were transformed to provide support in a more integrated and comprehensive manner, preferably in their own homes in the community. Yet, despite the welcome aspiration of community integration for all, people with complex mental health problems (also termed severe mental illness) have continued to require high levels of support, in inpatient settings and in the community. This group's needs make them highly dependent on their caregivers. The attitudes, knowledge and skills of the staff providing treatment and support is crucial to their recovery. Rehabilitation programmes provide a much-needed framework to guide practitioners and help them organise and focus their recovery-oriented approach. In this editorial, we will provide a non-exhaustive overview of such rehabilitation programmes and interventions to illuminate the wide scope and practical usability of these interventions for this group of people with complex mental health problems.

Promoting weight loss in people with schizophrenia: what do we still need to learn before implementing lifestyle interventions?

Holt et al show that a lifestyle intervention did not reduce weight in people with schizophrenia. The STEPWISE trial casts a critical focus on the challenges of improving physical health in people with schizophrenia. The trial underpins efforts to maintain momentum in overcoming the unacceptable health inequalities in this population.Declaration of interestNone.

Exercise, diet and educational interventions for metabolic syndrome in persons with schizophrenia: A systematic review

INTRODUCTION

Individuals with major psychotic disorders such as schizophrenia are at increased risk for developing metabolic syndrome due to lifestyle- and treatment-related factors. Numerous interventions have been tested in inpatient and outpatient mental health settings to decrease risk factors. Diet and exercise represent the mainstay of weight loss treatment. With this background the review aimed to evaluate the effects of psychoeducation, diet and physical activity interventions on reduction of metabolic syndrome risk factors such as BMI, Body weight, biochemical profiles in schizophrenia.

METHODS

The authors conducted database searches of PsychINFO, MEDLINE, Pubmed, Proquest, EBSCO and the Cochrane Database of Systematic Reviews, and manual searches from 1968 to 2017. Search indentified 11 studies that met the inclusion criteria. Study quality was critically appraised by 2 reviewers using established criteria. The outcome measures were body mass index, body weight, waist circumference, lipid profile, fasting glucose.

RESULTS

Interventions led to significant weight reduction (8 studies), reduced body mass index (5 studies), decreased waist circumference (4 studies) and lower blood glucose levels (5 studies). Dietician and nurse led interventions (6 studies). The studies showed non pharmacological interventions were effective in reducing risk factors.

CONCLUSION

This review was able to demonstrate effectiveness of peychoeducation, diet and physical activity interventions were helpful to decrease and manage antipsychotic-induced weight gain. Results showed lifestyle interventions are safer and effective for promoting decrease or maintenance of weight and it can be delivered at low cost, safe and improves quality of life.

Early prediction of olanzapine-induced weight gain for schizophrenia patients

The aim of this study was to determine whether weight changes at week 2 or other factors predicted weight gain at week 6 for schizophrenia patients receiving olanzapine. This study was the secondary analysis of a six-week trial for 94 patients receiving olanzapine (5 mg/d) plus trifluoperazine (5 mg/d), or olanzapine (10 mg/d) alone. Patients were included in analysis only if they had completed the 6-week trial (per protocol analysis). Weight gain was defined as a 7% or greater increase of the patient's baseline weight. The receiver operating characteristic curve was employed to determine the optimal cutoff points of statistically significant predictors. Eleven of the 67 patients completing the 6-week trial were classified as weight gainers. Weight change at week 2 was the statistically significant predictor for ultimate weight gain at week 6. A weight change of 1.0 kg at week 2 appeared to be the optimal cutoff point, with a sensitivity of 0.92, a specificity of 0.75, and an AUC of 0.85. Using weight change at week 2 to predict weight gain at week 6 is favorable in terms of both specificity and sensitivity. Weight change of 1.0 kg or more at 2 weeks is a reliable predictor.

Eating behavior of schizophrenic patients

ABSTRACT Objective To assess the eating behavior, food practices, nutritional and metabolic profiles of patients with schizophrenia undergoing treatment. Methods Cross-sectional exploratory descriptive qualitative study used a semi-structured questionnaire on the eating behavior, food practices, and perception of changes after the initiation of drug therapy and a quantitative method using anthropometric and body composition measurements, metabolic parameters, and 5-day dietary records to analyze nutrient ingestion of patients with schizophrenia in an outpatient clinic at a tertiary hospital (n=33). The qualitative data were analyzed and coded by three researchers and quantitative data were analyzed using descriptive exploratory statistics. Results The results of this study showed that schizophrenic patients presented high prevalence of excess weight (71.0%), metabolic syndrome (42.0%), dyslipidemia (62.0%), changes in appetite (76.0%), and increase in energy intake (74.2%), associated with important irregularities in eating behavior and food practices (such as irregularity of meals, emotional intake, high carbohydrate and fat intake, and low energy expenditure) and lifestyle (changes in social and work routines). Conclusion This eating profile may interact synergistically with psychotropic drugs to contribute to weight gain and metabolic changes in schizophrenia. Nutrition education may prevent and monitor the risk of metabolic and nutrition problems, irrespective of the medications used.

Antipsychotic Drugs: From Receptor-binding Profiles to Metabolic Side Effects

BACKGROUND

Antipsychotic-induced metabolic side effects are major concerns in psychopharmacology and clinical psychiatry. Their pathogenetic mechanisms are still not elucidated.

METHODS

Herein, we review the impact of neurotransmitters on metabolic regulation, providing insights into antipsychotic-induced metabolic side effects.

RESULTS

Antipsychotic drugs seem to interfere with feeding behaviors and energy balance, processes that control metabolic regulation. Reward and energy balance centers in central nervous system constitute the central level of metabolic regulation. The peripheral level consists of skeletal muscles, the liver, the pancreas, the adipose tissue and neuroendocrine connections. Neurotransmitter receptors have crucial roles in metabolic regulation and they are also targets of antipsychotic drugs. Interaction of antipsychotics with neurotransmitters could have both protective and harmful effects on metabolism.

CONCLUSION

Emerging evidence suggests that antipsychotics have different liabilities to induce obesity, diabetes and dyslipidemia. However this diversity cannot be explained merely by drugs'pharmacodynamic profiles, highlighting the need for further research.

One size doesn't fit all: A trial of individually tailored skills training

OBJECTIVES

This article describes a pilot test of an individually tailored program to improve community living and health self-management skills in older adults with serious mental illness.

METHOD

This study provided the Helping Older People Experience Success-Individually Tailored (HOPES-I) intervention, an adaptation of an empirically supported, manualized, group-based skills training program shown to improve community functioning, psychiatric symptoms, self-efficacy, and receipt of preventive health. HOPES-I targets 5 skill areas: leisure time, communication, independent living, friendships, and health self-management. We enrolled 47 adults age 50 and older (mean age = 62) with serious mental illness (38% schizophrenia spectrum, 62% mood disorders). Trained HOPES-I coaches evaluated participants' skills and functioning and engaged them in shared decision-making to select which curricular areas to receive. Participants received 1 HOPES-I session per week for 9-12 months, with assessments of overall psychosocial functioning and the 5 skill areas targeted by the program at baseline, postintervention, and at 3 and 6 months.

RESULTS

Participants with baseline impairments in overall functioning and in each of the skill areas targeted by the program demonstrated significant improvements on related outcome measures. Selection of specific HOPES-I curriculum was not associated with level of impairment in associated skill areas at baseline, but participants with more impairment overall chose and completed more curriculum modules.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results of this study support the feasibility and potential benefits of an individually tailored skills training program for the rapidly growing and vulnerable group of older people with serious mental illness. (PsycINFO Database Record

Perforated appendicitis in patients with schizophrenia: a retrospective cohort study

OBJECTIVE

Altered pain sensitivity may affect the outcome of appendicitis in patients with schizophrenia. We aimed to compare the prevalence of perforation in appendicitis between patients with and without schizophrenia.

DESIGN

Retrospective cohort study with random matching.

SETTING

A single tertiary medical centre in Japan.

PARTICIPANTS

From 1985 to 2013, 1821 cases of appendicitis requiring appendectomy were collected. Patients with schizophrenia and a cohort of randomly selected control subjects without schizophrenia who underwent appendectomy were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the rate of perforated appendicitis in patients with and without schizophrenia. Secondary outcome was the odds of perforated appendicitis by different clinical factors.

RESULTS

62 patients with schizophrenia and randomly sampled 200 non-schizophrenic patients were compared. The prevalence of perforation was 53% in patients with schizophrenia versus 17% in controls (p<0.0001). The adjusted OR for perforation were 4.87 (95% CI: 2.33 to 10.2) for schizophrenia, 3.35 (95% CI 1.51 to 7.45) for age >55 years and 2.18 (95% CI: 1.12 to 4.27) for delayed presentation.

CONCLUSION

Appendiceal perforation was more frequent in patients with schizophrenia than controls, which may be partly attributable to delayed presentation and altered responses to pain.

Association Between Cardiovascular Risk and Depressive Symptoms Among People With Serious Mental Illness

Depressive symptoms have debilitating effects on the physical health and functioning of people with serious mental illness. We examined change in depressive symptoms among overweight and obese adults with serious mental illness (n = 343) using data combined from two randomized trials comparing the 12-month In SHAPE program to a gym membership control condition. In SHAPE consists of a gym membership, weekly individual meetings with a fitness trainer, and instruction on healthy eating and nutrition. Depressive symptoms were measured at baseline, 3, 6, and 12 months. Change in depressive symptoms did not differ between groups, but depressive symptoms decreased over time across the entire sample (p = 0.045). At 12 months, reduced depressive symptoms were associated with clinically significant improved cardiorespiratory fitness (p = 0.030), 10% or more weight loss (p = 0.044), and cardiovascular risk reduction (p = 0.028) across both groups. Our findings suggest that participation in health promotion programs resulting in cardiovascular risk reduction may be associated with reduced depressive symptoms.

Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness.

METHOD

We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups.

RESULTS

Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (≤6-months or ≥12-months). Lifestyle interventions of ≤6-months duration showed greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ≥12-months duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%).

CONCLUSION

Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ≥12-months duration compared to ≤6-months duration appear to achieve more consistent outcomes, though effect sizes are similar for both shorter and longer duration interventions.

A cost analysis of implementing a behavioral weight loss intervention in community mental health settings: Results from the ACHIEVE trial

OBJECTIVE

In the ACHIEVE randomized controlled trial, an 18-month behavioral intervention accomplished weight loss in persons with serious mental illness who attended community psychiatric rehabilitation programs. This analysis estimates costs for delivering the intervention during the study. It also estimates expected costs to implement the intervention more widely in a range of community mental health programs.

METHODS

Using empirical data, costs were calculated from the perspective of a community psychiatric rehabilitation program delivering the intervention. Personnel and travel costs were calculated using time sheet data. Rent and supply costs were calculated using rent per square foot and intervention records. A univariate sensitivity analysis and an expert-informed sensitivity analysis were conducted.

RESULTS

With 144 participants receiving the intervention and a mean weight loss of 3.4 kg, costs of $95 per participant per month and $501 per kilogram lost in the trial were calculated. In univariate sensitivity analysis, costs ranged from $402 to $725 per kilogram lost. Through expert-informed sensitivity analysis, it was estimated that rehabilitation programs could implement the intervention for $68 to $85 per client per month.

CONCLUSIONS

Costs of implementing the ACHIEVE intervention were in the range of other intensive behavioral weight loss interventions. Wider implementation of efficacious lifestyle interventions in community mental health settings will require adequate funding mechanisms.

Patient, Provider, and System Factors Contributing to Patient Safety Events During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

This study aimed to explore patient-, provider-, and system-level factors that may contribute to elevated risk of patient safety events among persons with serious mental illness (SMI). We conducted a medical record review of medical/surgical admissions in Maryland hospitals from 1994 to 2004 for a community-based sample of adults with SMI (N = 790 hospitalizations). We estimated the prevalence of multiple patient, provider, and system factors that could influence patient safety among persons with SMI. We conducted a case crossover analysis to examine the relationship between these factors and adverse patient safety events. Patients' mental status, level of consciousness, disease severity, and providers' lack of patient monitoring, delay/failure to seek consultation, lack of trainee supervision, and delays in care were positively associated with adverse patient safety events (p < 0.05). Efforts to reduce SMI-related patient safety risks will need to be multifaceted and address both patient- and provider-level factors.

Improving Weight in People with Serious Mental Illness: The Effectiveness of Computerized Services with Peer Coaches

BACKGROUND

People with serious mental illness have high rates of obesity and related medical problems, and die years prematurely, most commonly from cardiovascular disease. Specialized, in-person weight management interventions result in weight loss in efficacy trials with highly motivated patients. In usual care, patient enrollment and retention are low with these interventions, and effectiveness has been inconsistent.

OBJECTIVE

To determine whether computerized provision of weight management with peer coaching is feasible to deliver, is acceptable to patients, and is more effective than in-person delivery or usual care.

DESIGN

Mixed-methods randomized controlled trial.

PARTICIPANTS

Two hundred seventy-six overweight patients with serious mental illness receiving care at a Veterans Administration medical center.

INTERVENTIONS

Patients were randomized to 1) computerized weight management with peer coaching (WebMOVE), 2) in-person clinician-led weight services, or 3) usual care. Both active interventions offered the same educational content.

MAIN MEASURES

Body mass index; and feasibility and acceptability of the intervention.

KEY RESULTS

At 6 months, in obese patients (n = 200), there was a significant condition by visit effect (F = 4.02, p = 0.02). The WebMOVE group had an average estimated BMI change from baseline to 6 months of 34.9 ± 0.4 to 34.1 ± 0.4. This corresponds to 2.8 kg (6.2 lbs) weight loss (t = 3.2, p = 0.001). No significant change in BMI was seen with either in-person services (t = 0.10, p = 0.92), or usual care (t = -0.25, p = 0.80). The average percentage of modules completed in the WebMOVE group was 49% and in the in-person group was 41% (t = 1.4, p = 0.17). When non-obese patients were included in the analyses, there was a trend towards a condition by visit effect (F = 2.8, p = 0.06). WebMOVE was well received, while the acceptability of in-person services was mixed.

CONCLUSIONS

Computerized weight management with peer support results in lower weight, and can have greater effectiveness than clinician-led in-person services. This intervention is well received, and could be feasible to disseminate.

Health Promotion for Young Adults With Serious Mental Illness

OBJECTIVE

Young adulthood represents a critical time to address elevated obesity rates and the risk of early mortality, particularly among people with serious mental illness. Few studies have assessed the benefits of lifestyle interventions targeting weight loss among these young adults. This study examined the impact of the 12-month In SHAPE lifestyle intervention on weight loss and fitness among overweight and obese young adults with serious mental illness (ages 21-30) compared with participants over age 30.

METHODS

Data were combined from three trials of the 12-month In SHAPE program delivered through community mental health centers. In SHAPE includes weekly fitness trainer meetings, a gym membership, and nutrition education. Primary outcomes were weight loss and change in fitness at 12 months.

RESULTS

Participants (N=194) had a schizophrenia spectrum disorder (53%) or a mood disorder (47%). The overall sample achieved significant weight loss and improved fitness; differences between young adults (N=29) and participants over age 30 (N=165) were not significant. An important finding was that 42% of young adults achieved clinically significant reductions in cardiovascular risk, defined as ≥5% weight loss or improved fitness (>50-m increase on the 6-Minute Walk Test), compared with 54% of adults over age 30 (a nonsignificant difference between age groups).

CONCLUSIONS

Among persons enrolled in a lifestyle intervention, overweight and obese young adults experienced benefits comparable with those of adults over age 30. Young adults with serious mental illness face high risk of gaining weight, but a meaningful proportion of these individuals can achieve clinically significant cardiovascular risk reduction, thus highlighting the need to promote lifestyle intervention participation in this group.