Weight Gain and Its Correlates Among Forensic Inpatients

Liraglutide 3.0 mg once daily for the treatment of overweight and obesity in patients hospitalised at a forensic psychiatric department: A 26-week open-label feasibility study

INTRODUCTION

Overweight and obesity constitute a major concern among patients treated at forensic psychiatric departments. The present clinical feasibility study aimed at investigating the extent to which glucagon-like peptide 1 receptor agonist (GLP-1RA) treatment with once-daily liraglutide 3.0 mg could be a feasible pharmacological treatment of these conditions in patients with schizophrenia spectrum disorders hospitalised in forensic psychiatry.

METHODS

The 26-week, open-label feasibility study included participants aged 18-65 years diagnosed with a severe mental illness and hospitalised at a forensic psychiatric department. At the time of inclusion, all participants fulfilled the indication for using liraglutide as a treatment for overweight and obesity. Participants' baseline examinations were followed by a 26-week treatment period with liraglutide injection once daily according to a fixed uptitration schedule of liraglutide, with a target dose of 3.0 mg. Each participant attended seven visits to evaluate the efficacy and adverse events. The primary endpoint was the number of "completers", with adherence defined as >80% injections obtained in the period, weeks 12-26. Determining whether liraglutide is a feasible treatment was pre-defined to a minimum of 75% completers.

RESULTS

Twenty-four participants were included in the study. Sex, male = 19 (79.2%). Mean age: 42.3 [25th and 75th percentiles: 39.1; 48.4] years; body mass index (BMI): 35.7 [31.7; 37.5] kg/m2; glycated haemoglobin (HbA1c): 37 [35; 39] mmol/mol. Eleven out of 24 participants (46%) completed the study. For the completers, the median net body weight loss after 26 weeks of participation was -11.4 kg [-15.4; -5.9]. The net difference in HbA1C and BMI was -2.0 mmol/mol [-4; -1] and -3.6 kg/m2 [-4.7; -1.8], respectively. The weight change and reduction in HbA1c and BMI were all statistically significant from baseline.

CONCLUSION

The study did not confirm our hypothesis that liraglutide is a feasible treatment for a minimum of 75% of the patients initiating treatment with liraglutide while hospitalised in a forensic psychiatric department. The high dropout rate may be due to the non-naturalistic setting of the clinical trial. For the proportion of patients compliant with the medication, liraglutide 3.0 mg was an efficient treatment for overweight.

Hospitalisation time is associated with weight gain in forensic mental health patients with schizophrenia or bipolar disorder

INTRODUCTION

People with mental disorders have higher mortality from lifestyle diseases than the general population. Forensic mental health patients (FMHPs) are often hospitalised for longer periods of time than non-FMHPs. Thus, hospitalisation may have a greater effect on the risk of lifestyle diseases in FMHPs.

OBJECTIVE

Investigate associations between proportional hospitalisation time (PHT) and change in body weight or other cardiometabolic risk factors among FMHPs.

METHODS

Retrospective cohort study including all FMHPs with schizophrenia or bipolar disorder, prescribed antipsychotics, and treated between 01 January 2016 and 06 April 2020 in the Region of Southern Denmark either in forensic units or as outpatients. Associations between PHT and, respectively, primary and secondary outcomes were analysed using linear regression. PHT was determined between each measurement of the outcomes as the number of days hospitalised divided by the total number of days within the time-period. The primary outcome was weight change and secondary outcomes were change in waist circumference (WC), blood pressure, estimated average glucose (eAG), HDL, LDL, total cholesterol, and triglycerides. Analyses were adjusted for gender, age, smoking, and antipsychotics.

RESULTS

The cohort included 490 FMHPs, of which 440 were diagnosed with schizophrenia. PHT had a significant positive dose-response association with weight change, with an estimated difference of +4.0 kg/year for FMHPs who were hospitalised 100% of the time, compared to FMHPs who were exclusively treated as outpatients. The association interacted with baseline BMI. From the secondary outcomes, the association with PHT was only statistically significant for WC.

CONCLUSIONS

PHT was positively associated with weight gain.

Health behaviours of forensic mental health service users, in relation to smoking, alcohol consumption, dietary behaviours and physical activity-A mixed methods systematic review

WHAT IS KNOWN ON THE SUBJECT

People with mental disorders have increased risk of dying from diabetes and cardiovascular diseases compared to the general population. Diabetes and cardiovascular diseases are preventable by improved lifestyle regarding smoking, alcohol consumption, physical activity and dietary behaviours. Forensic mental health service users are treated for longer periods of time compared to non-forensic mental health service users, giving the opportunity to affect the lifestyle for a substantial period of time.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This review gathers existing research on forensic mental health service users' lifestyle regarding smoking, alcohol consumption, physical activity, and dietary behaviours and factors influencing it. The lifestyle was found to be unfavourable with many patients being smokers, having problematic alcohol consumption, being physically inactive and eating a diet of poor nutritional value and rich in calories. Therefore, it seems likely that an unfavourable lifestyle is one reason for the excess mortality from diabetes and cardiovascular diseases. Smoking cessation and improving dietary habits was perceived difficult, but nicotine replacement and practical advice was suggested to support a change.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The treatment period gives an opportunity to improve the lifestyle of forensic mental health service users to prevent diabetes and cardiovascular diseases in this high-risk group. We recommend a holistic approach, when planning the prevention activities, since activities that are perceived fun are more likely to succeed.

ABSTRACT

Introduction People with mental disorders have increased risk of dying from diabetes and cardiovascular diseases, both of which can be prevented by lifestyle. Aim To review existing research, in order to investigate the characteristics of, and factors that influence forensic mental health service users' (FMU) health behaviours. Method We searched PubMed, CINAHL, PsycInfo and Scopus for primary research on FMU's health behaviours regarding smoking, alcohol consumption, physical activity and dietary behaviours, and factors that influence them. Results We found 13 eligible studies. The findings consistently indicated the presence of unfavourable health behaviours in FMU: Smoking, problematic alcohol consumption, physical inactivity and a high-calorie diet of poor nutritional value. Changing smoking and dietary habits was perceived as difficult, but nicotine replacement and practical advice were suggested to support change. Discussion The existing research on FMU's health behaviours is sparse. In particular, there is a lack of research on factors that influence health behaviours. From our findings, it seems likely that FMU's unfavourable health behaviours contribute to their increased risk of dying from diabetes and cardiovascular diseases. Implications for practice FMU's health behaviours should be improved to prevent diabetes and cardiovascular diseases in this high-risk group.

The Other Obesity Epidemic-Of Drugs and Bugs

Chronic psychiatric patients with schizophrenia and related disorders are frequently treatment-resistant and may require higher doses of psychotropic drugs to remain stable. Prolonged exposure to these agents increases the risk of weight gain and cardiometabolic disorders, leading to poorer outcomes and higher medical cost. It is well-established that obesity has reached epidemic proportions throughout the world, however it is less known that its rates are two to three times higher in mentally ill patients compared to the general population. Psychotropic drugs have emerged as a major cause of weight gain, pointing to an urgent need for novel interventions to attenuate this unintended consequence. Recently, the gut microbial community has been linked to psychotropic drugs-induced obesity as these agents were found to possess antimicrobial properties and trigger intestinal dysbiosis, depleting Bacteroidetes phylum. Since germ-free animals exposed to psychotropics have not demonstrated weight gain, altered commensal flora composition is believed to be necessary and sufficient to induce dysmetabolism. Conversely, not only do psychotropics disrupt the composition of gut microbiota but the later alter the metabolism of the former. Here we review the role of gut bacterial community in psychotropic drugs metabolism and dysbiosis. We discuss potential biomarkers reflecting the status of Bacteroidetes phylum and take a closer look at nutritional interventions, fecal microbiota transplantation, and transcranial magnetic stimulation, strategies that may lower obesity rates in chronic psychiatric patients.

Assessment of adherence to oral antipsychotic medications: What has changed over the past decade?

INTRODUCTION

In a previous review, spanning 3 decades, we found that self-report and other non-objective measures were the primary means of assessing adherence to oral antipsychotic medications for individuals with schizophrenia. Moreover, consensus regarding the definition of adherence was completely lacking. Here, we examined the next decade of studies to determine what may have changed.

METHOD

We searched the peer reviewed literature published between January 1, 2007 and December 31, 2017 using Google scholar, Science Direct, CINAHL, PsychINFO, PsychARTICLES and Medline. Search terms were medication adherence or medication compliance or medication acceptance or medication follow-through or medication concordance or medication persistence AND schizophrenia. We included articles that assessed adherence behavior.

RESULTS

The search yielded 663 articles, 363 of these were eliminated. Included studies represent over 560,000 individuals. Definitions of adherence remain variable with cutoffs from 67% to 95%. Subjective measures of adherence remain the most commonly used. However, the use of objective measures has significantly increased, as has the use of electronic claims data. However, the absolute number of studies using objective measures remains low and very few approaches identify the amount of medication actually taken.

CONCLUSIONS

Some movement toward more standardization and the use of more objective measures of adherence has been made over the past decade. However, objective measures continue to be underutilized and definitions remain variable. Assessing adherence in less than optimal ways calls into question the results of studies purporting to identify reasons for problem adherence and to elucidate the relationships among adherence and other variables.

Assessment of Risk for Seclusion Among Forensic Inpatients: Validation and Modification of the Risk of Administrative Segregation Tool (RAST)

Seclusion is used in psychiatric care to protect patients and staff or to manage aggression but may have adverse effects. The ability to identify at-risk patients could help reduce seclusion. This study tested the Risk of Administrative Segregation Tool's (RAST) ability to predict any seclusions among 229 male forensic inpatients followed for up to 1 year of hospitalization, and days spent secluded, controlling for length of stay. RAST scores were lower than in correctional samples. The RAST did not predict seclusions in Year 1, but modification of three items to fit the forensic population (RAST-F) offered a small improvement. Among 62 patients hospitalized for more than 1 year, the RAST significantly predicted seclusions in Year 2, and the modifications improved prediction. The present modest findings support the RAST's potential to help identify patients most in need of clinical efforts to avert seclusion. Replication in larger samples, including female patients, is needed.