Increased mortality in schizophrenia due to cardiovascular disease - a non-systematic review of epidemiology, possible causes and interventions

Background: Schizophrenia is among the major causes of disability worldwide and the mortality from cardiovascular disease (CVD) is significantly elevated. There is a growing concern that this health challenge is not fully understood and efficiently addressed. Methods: Non-systematic review using searches in PubMed on relevant topics as well as selection of references based on the authors’ experience from clinical work and research in the field. Results: In most countries, the standardized mortality rate in schizophrenia is about 2.5, leading to a reduction in life expectancy between 15 and 20 years. A major contributor of the increased mortality is due to CVD, with CVD mortality ranging from 40 to 50% in most studies. Important causal factors are related to lifestyle, including poor diet, lack of physical activity, smoking, and substance abuse. Recent findings suggest that there are overlapping pathophysiology and genetics between schizophrenia and CVD-risk factors, further increasing the liability to CVD in schizophrenia. Many pharmacological agents used for treating psychotic disorders have side effects augmenting CVD risk. Although several CVD-risk factors can be effectively prevented and treated, the provision of somatic health services to people with schizophrenia seems inadequate. Further, there is a sparseness of studies investigating the effects of lifestyle interventions in schizophrenia, and there is little knowledge about effective programs targeting physical health in this population. Discussion: The risk for CVD and CVD-related deaths in people with schizophrenia is increased, but the underlying mechanisms are not fully known. Coordinated interventions in different health care settings could probably reduce the risk. There is an urgent need to develop and implement effective programs to increase life expectancy in schizophrenia, and we argue that mental health workers should be more involved in this important task

Quality of clinical management of cardiometabolic risk factors in patients with severe mental illness in a specialist mental health care setting

Purpose Cardiometabolic disease in patients with severe mental illness is a major cause of shortened life expectancy. There is sparse evidence of real-world clinical risk prevention practice. We investigated levels of assessments of cardiometabolic risk factors and risk management interventions in patients with severe mental illness in the Norwegian mental health service according to an acknowledged international standard. Methods We collected data from 264 patients residing in six country-wide health trusts for: (a) assessments of cardiometabolic risk and (b) assessments of levels of risk reducing interventions. Logistic regressions were employed to investigate associations between risk and interventions. Results Complete assessments of all cardiometabolic risk variables were performed in 50% of the participants and 88% thereof had risk levels requiring intervention according to the standard. Smoking cessation advice was provided to 45% of daily smokers and 4% were referred to an intervention program. Obesity was identified in 62% and was associated with lifestyle interventions. Reassessment of psychotropic medication was done in 28% of the obese patients. Women with obesity were less likely to receive dietary advice, and use of clozapine or olanzapine reduced the chances for patients with obesity of getting weight reducing interventions. Conclusions Nearly nine out of the ten participants were identified as being at cardiometabolic high risk and only half of the participants were adequately screened. Women with obesity and patients using antipsychotics with higher levels of cardiometabolic side effects had fewer adequate interventions. The findings underscore the need for standardized recommendations for identification and provision of cardiometabolic risk reducing interventions in all patients with severe mental illness.publishedVersio

Association between cannabis use and symptom dimensions in schizophrenia spectrum disorders: an individual participant data meta-analysis on 3053 individuals

Background: The association between cannabis use and positive symptoms in schizophrenia spectrum disorders is well documented, especially via meta-analyses. Yet, findings are inconsistent regarding negative symptoms, while other dimensions such as disorganization, depression, and excitement, have not been investigated. In addition, meta-analyses use aggregated data discarding important confounding variables which is a source of bias. Methods: PubMed, ScienceDirect and PsycINFO were used to search for publications from inception to September 27, 2022. We contacted the authors of relevant studies to extract raw datasets and perform an Individual Participant Data meta-analysis (IPDMA). Inclusion criteria were: psychopathology of individuals with schizophrenia spectrum disorders assessed by the Positive and Negative Syndrome Scale (PANSS); cannabis-users had to either have a diagnosis of cannabis use disorder or use cannabis at least twice a week. The main outcomes were the PANSS subscores extracted via the 3-factor (positive, negative and general) and 5-factor (positive, negative, disorganization, depression, excitement) structures. Preregistration is accessible via Prospero: ID CRD42022329172. Findings: Among the 1149 identified studies, 65 were eligible and 21 datasets were shared, totaling 3677 IPD and 3053 complete cases. The adjusted multivariate analysis revealed that relative to non-use, cannabis use was associated with higher severity of positive dimension (3-factor: Adjusted Mean Difference, aMD = 0.34, 95% Confidence Interval, CI = [0.03; 0.66]; 5-factor: aMD = 0.38, 95% CI = [0.08; 0.63]), lower severity of negative dimension (3-factor: aMD = -0.49, 95% CI [-0.90; -0.09]; 5-factor: aMD = -0.50, 95% CI = [-0.91; -0.08]), higher severity of excitement dimension (aMD = 0.16, 95% CI = [0.03; 0.28]). No association was found between cannabis use and disorganization (aMD = -0.13, 95% CI = [-0.42; 0.17]) or depression (aMD = -0.14, 95% CI = [-0.34; 0.06]). Interpretation: No causal relationship can be inferred from the current results. The findings could be in favor of both a detrimental and beneficial effect of cannabis on positive and negative symptoms, respectively. Longitudinal designs are needed to understand the role of cannabis is this association. The reported effect sizes are small and CIs are wide, the interpretation of findings should be taken with caution

Using motivational techniques to reduce cardiometabolic risk factors in long term psychiatric inpatients: A naturalistic interventional study

Background People with severe mental illness have markedly reduced life expectancy; cardiometabolic disease is a major cause. Psychiatric hospital inpatients have elevated levels of cardiometabolic risk factors and are to a high degree dependent of the routines and facilities of the institutions. Studies of lifestyle interventions to reduce cardiometabolic risk in psychiatric inpatients are few. The current study aimed at assessing the feasibility and effects of a lifestyle intervention including Motivational Interviewing (MI) on physical activity levels, cardiometabolic risk status and mental health status in psychotic disorder inpatients. Methods Prospective naturalistic intervention study of 83 patients at long term inpatient psychosis treatment wards in South-Eastern Norway. Patients were assessed 3–6 months prior to, at start and 6 months after a life-style intervention program including training of staff in MI, simple changes in routines and improvements of facilities for physical exercise. Assessments were done by clinical staff and included level of physical activity, motivation, life satisfaction, symptom levels (MADRS, AES-C, PANSS, and GAF) as well as anthropometric and biochemical markers of cardiometabolic risk. A mixed model was applied to analyze change over time. Results A total of 88% of patients received MI interventions, with a mean of 2.5 MI interventions per week per patient. The physical activity level was not increased, but activity level was positively associated with motivation and negatively associated with positive symptoms. Triglyceride levels and number of smokers were significantly reduced and a significant decrease in symptom levels was observed. Conclusions The current results suggest that a simple, low cost life-style intervention program focusing on motivational change is feasible and may reduce symptoms and improve lifestyle habits in psychosis patients in long term treatment facilities. Similar programs may easily be implemented in other psychiatric hospitals.submittedVersio

Substance use in psychotic disorder : Use patterns and relation to clinical and cognitive characteristics in schizophrenia and bipolar disorder

Lege og forsker Petter Andreas Ringen har undersøkt bruken av rusmidler i de to store psykiatriske diagnosegruppene schizofreni og bipolar lidelse. I sin avhandling Substance use in psychotic disorder; use patterns and relation to clinical and cognitive characteristics in schizophrenia and bipolar disorder har Petter Andreas Ringen og hans medarbeidere funnet at det var 40 % flere som hadde prøvd rusmidler i disse pasientgruppene enn i den generelle befolkningen i Oslo. Pasienter med schizofreni så ut til å bruke mer ”sterke stoffer” som amfetamin og kokain enn de med bipolar lidelse og de brukte også flere stoffer og hadde hyppigere bruk. Høyere bruk var relatert til mer symptomer hos de med schizofreni enn hos de med bipolar lidelse. Cannabisbruk ble funnet å ha sammenheng med dårligere nevrokognitiv fungering hos schizofrenipasienter, men dette var ikke tilfelle hos pasienter med bipolar lidelse. Bruk av rusmidler er et betydelig problem hos mennesker med psykiatriske lidelser, dette gjelder i særlig grad ved de to store diagnosegruppene schizofreni og bipolar lidelse. Lite har til nå vært kjent om det er forskjeller mellom lidelsene i forhold til hvordan de bruker rusmidlene. Rusmiddelbruk ved psykiatrisk lidelse er kjent for å være koblet med større sykelighet og sosiale problemer, men det er usikkert om dette er like uttalt for alle lidelser. Funnene tyder på at det er forskjeller mellom pasientgrupper i forhold til hvordan man bruker rusmidler og hvordan bruk har sammenheng med plager og fungering. Ringen har blant annet konkludert med at funnene understreker hvor viktig god kartlegging av rusmiddelbruk er ved alvorlige sinnslidelser. Dersom funnene bekreftes kan det se ut til at behandlingstinnsatsen bør tilpasses mer til type lidelse

Ta imot kasteballene. Pasientforløp for alvorlig psykisk syke: Utfordringer i samhandling mellom oslobydeler og sykehus

Dette utviklingsprosjektet er gjennomført av fire toppledere, to fra spesialisthelsetjenesten og to fra kommunehelsetjenesten, som alle har ansvarsområde inne fagfeltet psykisk helse for innbyggere i Oslo kommune. Prosjektet er en del av nasjonalt topplederprogram for spesialisthelsetjenesten og kommunehelsetjenesten på Handelshøyskolen BI i perioden 2021-2022. Vi undersøkte hvordan bedre overgangene fra sykehus til bydel, og vis-a–versa, for innbyggere med alvorlig psykisk lidelse med behov for lengre døgninnleggelse i perioder. Vi ønsker å bedre både kvaliteten og organiseringen av pasientforløpet. Dette innebærer også at pasienten skal medvirke så mye som mulig og oppleve seg sett og ivaretatt. Ved bruk av trippel diamant metoden prøvde vi først å forstå problemet, deretter utforske løsninger og så teste dem ut. Vi har innhentet informasjon fra pasienter og ansatte, både fra bydeler i Oslo kommune og Klinikk for psykisk helse og avhengighet ved Oslo Universitetssykehus, brukerrepresentanter, medstudenter og andre interessenter. Vi brukte blant annet faglige perspektiver som verdikonfigurasjoner, endrings- og grensearbeid og teori om samhandling og styring. Utfordringene vi har identifisert er knyttet til stor grad av konkurrerende grensearbeid og tradisjonelle verdiskapingsperspektiver. De ansatte i helsetjenesten opplever at arbeidet med de spesielt ressurskrevende pasienter i psykisk helsevern ofte innebærer utfordringer med overgangene og manglende informasjonstilgang, kontinuitet og helhetsperspektiv. Pasientene selv opplever manglende medvirkning, forståelse og involvering. Vi konkluderte med at tiltaket om videreutvikling av Prio-flyt-møter (PFM) med større fokus på hva som er viktig for pasienten kan være effektivt og gjennomførbart. PFM er en fast samhandlingsarena for pasientforløp mellom kommune og sykehus. Prinsippet er at hvis en part (for eksempel bydel eller DPS) har en konkret pasientsak som de har utfordringer med, kan den bringes inn til møtet. Sammen finner bydelen og DPSet den beste løsningen for alle parter. Saken kan følges opp i de påfølgende møtene for å høre hvordan det har gått, og gjøre eventuelle justeringer. Styring av disse samhandlingsprosessene og videre utvikling av PFM er mulig - til beste for fremtidig samhandling rundt pasientforløpene og for livene til de mest alvorlig psykisk syke

Predictors for antipsychotic dosage change in the first year of treatment in schizophrenia spectrum and bipolar disorders

Background: Use of antipsychotic medication is central in the treatment of psychotic disorders. However, there is limited knowledge about prescription practice of antipsychotics in the critical early phase of these disorders. Clinical guidelines recommend low dosages, but no discontinuation of antipsychotic medication during the first year of treatment in first episode patients. The main aim of this study was to identify clinical predictors for dosage change or discontinuation of antipsychotics during this period. Methods: A total of 426 antipsychotic-using patients with schizophrenia spectrum or bipolar disorder, including both a first treatment sample and a sample of patients with previous treated episodes (“multi-episode” sample) from the same diagnostic groups, underwent thorough clinical and sociodemographic assessment at study baseline and after 1 year. Prescribed dosage levels at baseline and follow-up and change in dosage or discontinuation of antipsychotics from baseline to follow-up were compared between groups, controlling for possible confounders. Results: We found reduced dosages over the first year in both first treatment groups across diagnoses, but not in multi-episode groups. Weight increase predicted dosage reduction in the schizophrenia group, while the level of psychotic symptoms at baseline predicted dosage reduction in the bipolar group. We found higher baseline levels of antipsychotic use in the schizophrenia group than in the bipolar group. Conclusion: We found indications of a trans-diagnostic reduction of prescribed dosages of antipsychotics over the first year in treatment, but with different predictors for this reduction in the two diagnostic groups. The findings increase the understanding of drivers of early medication change in psychotic disorder

Reliability and validity of the self-report version of the apathy evaluation scale in first-episode Psychosis: Concordance with the clinical version at baseline and 12 months follow-up

Negative symptoms have traditionally been assessed based on clinicians’ observations. The subjective experience of negative symptoms in people with psychosis may bring new insight. The Apathy Evaluation Scale (AES) is commonly used to study apathy in psychosis and has corresponding self-rated (AES-S) and clinician-rated (AES-C) versions. The aim of the present study was to determine the validity and reliability of the AES-S by investigating its concordance with the AES-C. Eighty-four first-episode (FEP) patients completed the shortened 12-item AES-S and AES-C at baseline (T1) and 12 months (T2). Concordance was studied by degree of correlation, comparison of mean scores, and change and difference between diagnostic groups. The Positive and Negative Symptom Scale (PANSS) was used to study convergent and discriminative properties. High concordance was found between AES-S and AES-C at both T1 and T2 regarding mean values, change from T1 to T2, and the proportion with high levels of apathy. Both versions indicated high levels of apathy in FEP, while associations with PANSS negative symptoms were weaker for AES-S than AES-C. Controlling for depression did not significantly alter results. We concluded that self-rated apathy in FEP patients is in concordance with clinician ratings, but in need of further study

Vocational rehabilitation augmented with cognitive behavioral therapy or cognitive remediation for individuals with schizophrenia: a 5-year follow-up study

Introduction: Although employment is an important part of recovery for individuals with schizophrenia spectrum disorders, the employment rate for this group remains low. Increasing evidence supports the use of augmented vocational rehabilitation (VR) programs to improve occupational outcome. The aim of this study is to explore 5-year follow-up registry data from the JUMP study, a VR program for individuals with schizophrenia spectrum disorders, specifically with regard to competitive employment outcome and predictors of competitive employment. The VR was augmented with either cognitive remediation (CR) or elements from cognitive behavior therapy (CBT). Methods: One hundred and forty eight participants with schizophrenia spectrum disorders from six Norwegian counties received 10 months VR augmented with either CR (n ¼ 64) or CBT (n ¼ 84). Both competitive and sheltered workplaces were used. Assessments were conducted at baseline, at post intervention and at 2-year follow-up. Data on employment status at 5-year follow-up was obtained by registry. Results: At 5-year follow-up 55.4% were engaged in working activity, of which 22.3% had obtained competitive employment. A further 18.2% had work placements in competitive workplaces. Number of received intervention hours and competitive employment at 2-year follow-up emerged as significant predictors of competitive employment. IQ and intervention type in marginal favor of CBT were predictors on trend level. Conclusion: To the best of our knowledge, this is the first study investigating competitive employment at 5-year follow-up for individuals with schizophrenia spectrum disorders. The results add to existing evidence that competitive employment is attainable for this group