Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia

OBJECTIVE: The purpose of this study was to assess the effects of patients' awareness of their illness on the clinical presentation, management, and course of nonadherence to antipsychotic medications among patients with schizophrenia. METHODS: A national survey was conducted of psychiatrists who were treating patients with schizophrenia. The survey was sent to 771 psychiatrists, of whom 534 responded, for a response rate of 69 percent. The psychiatrists were asked to report on presentation, management, and course for one adult patient with schizophrenia who had been under their care for at least one year and who had been nonadherent to oral antipsychotics at some point in the past year. Patients who were aware that they had a mental illness were compared with those who were not aware. RESULTS: Of the 534 respondent psychiatrists, 310 reported on an eligible patient, and 300 of these patients were classified by illness awareness. Ninety-seven patients, or 32 percent, were not aware that they had a mental illness. These patients who lacked awareness had significantly longer episodes of antipsychotic nonadherence, were more likely to completely cease taking the antipsychotic medication, were more likely to have severe positive symptoms, and were more likely to be psychiatrically hospitalized after nonadherence than those who were aware of their illness. Psychological interventions and several types of family interventions were significantly less effective among patients who lacked awareness. CONCLUSIONS: A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions.     

Correlates of religious service attendance and contact with religious leaders among persons with co-occurring serious mental illness and type 2 diabetes

The purpose of this study was to examine the prevalence and correlates of religious participation among persons with co-occurring serious mental illness and type 2 diabetes. Among 201 outpatients, 53% attended religious services, 36% had regular contact with a religious leader, and 15% received assistance from a religious leader. Persons with schizophrenia and African Americans were more likely to attend services and have contact with religious leaders. Both attendance at religious services and regular contact with a religious leader were linked to higher quality of life in selected domains, but not associated with global health ratings or glycosylated hemoglobin (HbA1c) levels. Results indicate that there are important diagnostic and racial differences in religious participation, and that religious participation may be a resilience factor that supports enhanced quality of life for persons with serious mental illness and diabetes.     

急性动脉粥样硬化型脑梗死患者血清CXCL16水平与2型糖尿病的相关性研究

目的探讨血清CXCL16水平与2型糖尿病、急性脑梗死的关系。方法选取2013年1月至2013年12月在石河子大学医学院第一附属医院神经内科住院的30例脑梗死患者(CI组)、30例2型糖尿病患者(DM组)、30例2型糖尿病合并脑梗死患者(DM+CI组)及30例同期体检健康者(对照组)。比较各组受检者的总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白(LDL)、Hcy、糖化血红蛋白(Hb A1c)、CXC趋化因子配体16(CXCL16)水平,采用Pearson相关分析CXCL16的相关因素;采用二分类Logistic回归分析2型糖尿病合并脑梗死的影响因素。结果 1 4组受检者TG、TC、LDL、CXCL16、Hb A1c、Hcy水平比较,除TC外,差异均有统计学意义(P﹤0.05);CI+DM组、DM组、CI组CXCL16的水平均高于对照组,其中CI+DM组最高[0.747(0.839),P﹤0.05];2血糖控制未达标(Hb A1c≥6.5%)者血清CXCL16水平高于血糖控制达标(Hb A1c﹤6.5%)者[(0.839±0.708)ng·m L-1与(0.526±0.865)ng·m L-1,t=-2.005,P=0.047];3 Pearson相关分析显示,血清CXCL16水平与NIHSS评分、Hb A1c水平均成正相关(r分别为0.318,0.376,P值分别为0.013,0.001)。结论 CXCL16在急性脑梗死及糖尿病患者血清中表达明显增高,与神经功能缺损程度及血糖水平有明显的正相关关系,可以作为评估急性动脉粥样硬化型脑梗死及合并2型糖尿病患者预后的一个指标。     

Diabetes treatment among VA patients with comorbid serious mental illness

OBJECTIVE: Patients with serious mental illnesses, such as schizophrenia, bipolar disorder, and other psychoses, may be less likely to receive adequate care for chronic medical conditions than patients without serious mental illness. The quality and outcomes of diabetes care were compared in an observational study among patients with and without serious mental illness. METHODS: National data were studied for 36,546 individuals receiving care within the U.S. Department of Veterans Affairs (VA) health care system. Widely used diabetes quality-of-care measures and intermediate outcomes were compared for patients with diabetes and serious mental illness and age-matched patients with diabetes who did not have a serious mental illness. Patients' use of health services was also examined. RESULTS: During fiscal year 1998, patients with diabetes and serious mental illness were as likely as patients with diabetes alone to have their hemoglobin A1c, low-density lipoproteins (LDL), and cholesterol measured; both groups had comparable A1c, LDL, and cholesterol values. Patients with diabetes and serious mental illness had more outpatient visits, both primary care and specialty visits, and made more multiclinic visits, including visits to both primary care and mental health services on the same day. CONCLUSIONS: In the VA, patients with diabetes and serious mental illness appear to receive diabetes care that is comparable with the care that other patients with diabetes receive, possibly because of increased levels of contact with the health system and the VA's integration of medical and mental health services.     

Effects of psychotropics on glycosylated hemoglobin (HbA1c) in a cohort of bipolar patients

OBJECTIVES: Research suggests that certain psychotropics may induce glucose regulatory dysfunction. Hyperglycemia increases levels of glycosylated hemoglobin (HbA1c). This study investigated the relationship between psychotropic use and concentrations of HbA1c in bipolar patients who were presumably non-diabetic. METHODS: Analysis was conducted on 76,671 patients with bipolar disorder (BPD) from the Integrated Health Care Information Services (IHCIS). Included were 381 patients with at least two measurements of HbA1c taken between January 1, 1997 and June 30, 2002. Individuals with only 1 HbA1c measure, diagnosed with type 1 or type 2 diabetes according to the International Classification of Diseases (ICD-9), and/or who were using any anti-diabetes medication were excluded from the cohort. We compared HbA1c levels from first to final HbA1c measurements. The types of psychotropic medications used by the patients were examined. RESULTS: A total of 197 (51.9%) BPD patients had an abnormal initial HbA1c test result (defined as HbA1c>7). Thirty patients were taking antipsychotics, 24 mood stabilizers (anticonvulsants), 10 lithium, 51 antidepressants and 116 a combination of medications. A total of 150 patients were not taking psychotropic medications. HbA1c levels declined significantly in patients taking psychotropic medication(s) [mean=7.5, standard deviation (SD)=2.1% versus mean=7.0, SD=1.8%; p<0.001] and in patients not taking psychotropic medication(s) (mean=7.4, SD=2.0% versus mean=7.0, SD=1.9%; p<0.001). The only exception to this finding was among patients taking antipsychotics, where there was a slight increase (not statistically significant) during this period (mean=7.0, SD=1.8% versus mean=7.2, SD=3.7%; p=0.791). CONCLUSIONS: These results support findings suggesting an increased risk of type 2 diabetes in BPD patients. Mood stabilizers (anticonvulsants), antidepressants and lithium in monotherapy and combination were associated with a decrease in HbA1c levels. Although not statistically significant, antipsychotic medications were associated with an increase in HbA1c in this population.     

Obesity and associated complications in patients with severe mental illnesses: a cross-sectional survey

BACKGROUND: This naturalistic cross-sectional survey of patients with severe mental illnesses explores the association between important variables and obesity, extreme obesity, diabetes mellitus type 2, hypertension, and hyperlipidemia in the clinical environment. METHOD: Weight and height were obtained from 560 patients with severe mental illnesses (including DSM-IV schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder) at central Kentucky inpatient and outpatient facilities to estimate their body mass index (BMI). Chart diagnoses of diabetes mellitus, hypertension, and hyperlipidemia were obtained. RESULTS: When comparing the patients with severe mental illnesses with Kentucky adults from the general population, the odds ratio (OR) of obesity (BMI > or = 30 kg/m(2)) was 2.6 (95% confidence interval [CI] = 2.2 to 3.0), and the OR of diabetes mellitus was 2.9 (95% CI = 2.3 to 3.6). Female gender, African American race, early start of psychiatric medication, and long psychiatric medication duration were significantly associated with obesity. Current alcohol and nicotine use exhibited significant ORs of obesity lower than 1, particularly in males. Obesity was closely associated with hypertension, type 2 diabetes mellitus, and hyperlipidemia. These complications were closely associated with each other and may indicate a further progression of obesity after aging. CONCLUSIONS: These results suggest a complex pattern of variables that may influence the development of obesity and its complications in patients with severe mental illnesses, but they need replication. The major factors associated with obesity appear to be a long-term illness or treatment duration and substance use. The former may be more important in females, while the latter may be more important in males. Clinical diagnoses (schizophrenic or mood disorders) or current treatment did not appear to be fundamental factors.     

The Metabolic Syndrome in Patients With Severe Mental Illnesses

BACKGROUND: Since the introduction of the first atypical antipsychotics in the early 1990s, this class of medication has been increasingly relied upon for the treatment of a variety of patients with psychotic and mood disorders.DATA SOURCES: The following retrospective review was derived from the MEDLINE database using the search terms metabolic syndrome, insulin resistance, obesity, diabetes, severe mental illness, schizophrenia, bipolar disorder, mood disorders, depression, unipolar depression, and prevalence from 1966 to the present. LITERATURE SYNTHESIS: Coincident with the growing usage of these agents, there have been a growing number of literature reports of changes in metabolic homeostasis among patients taking these medications. These changes have led to interest in evaluating whether there is a relationship among these mental illnesses, their psychiatric treatments, and certain physical comorbidities known collectively as the metabolic syndrome. This article reviews the existing literature around the metabolic syndrome in patients with severe mental illnesses. CONCLUSION: Patients with severe mental illnesses, particularly schizophrenia and chronic mood disorders, demonstrate a higher prevalence of metabolic syndrome or its components compared with the general population. Based upon this increased risk in these patients, baseline and periodic medical evaluations should become a standard component in ongoing clinical assessment.     

Long-term glucose control among type 2 diabetes patients with and without serious mental illness

Although studies suggest that patients with diabetes with a serious mental illness (SMI) have poor diabetes outcomes, reports conflict regarding the quality of their diabetes care and level of glucose control. In an observational follow-up to our initial cross-sectional study, we compared glucose control (glycosylated hemoglobin [HbA1c]) between patients with diabetes with SMI versus those without SMI at two postbaseline assessments during an approximately 5-year period. Both groups continued to have glucose levels higher than what is considered good control and neither group demonstrated a significant change in mean HbA1c at the two follow-up time points. Those with SMI continued to have lower HbA1c levels than those without SMI even after adjusting for potential confounders. More effective strategies are needed to assist patients with diabetes to improve the management of their glucose levels.     

Psychotropic drug use in older people with mental illness with particular reference to antipsychotics: a systematic study of tolerability and use in different diagnostic groups

OBJECTIVE: The objective of the study was to provide observational clinical data on psychotropic drugs used in older people with mental illness. METHODS: This was an observational, single-centre, one-week prevalence study of psychiatric symptoms, disorders and psychotropic drug use in older with mental illness cared for by the South West people Yorkshire Mental Health NHS Trust (Wakefield Locality), UK. The clinical assessment included completion of the Psychosis Evaluation Tool for Common use by Caregivers. RESULTS: A total of 593/660 older patients with mental illness (mean +/- SD age, 76 +/- 8.1 years were assessed. 44.5% had dementia (excluding vascular dementia) and 33.7% had a mood disorder. Of the total, 20.4% did not receive CNS active medication. Of those receiving CNS active medication approximately half (51.3%) took antipsychotics and 46.2% antidepressants. Of 304 patients taking antipsychotics, 87% took only one medication. However, patients with schizophrenia and related disorders were significantly more likely to be prescribed two or more antipsychotics (p < 0.001). Risperidone was the most frequently prescribed antipsychotic (n = 136, 44.7%). Risperidone doses were significantly lower for patients with dementia and mood disorders than with schizophrenia (p < 0.002). Side-effects from antipsychotics were significantly greater in patients with schizophrenia, suggesting a dose-related effect. Risperidone appeared to be well tolerated in all patients with no evidence of cerebrovascular side-effects in patients taking it. CONCLUSIONS: Psychotropic drugs were commonly used by older people in contact with mental health services. The doses of antipsychotics used in dementia and affective disorders were significantly lower than in schizophrenia. Risperidone was the most commonly used drug in all diagnostic groups including dementia. Despite a relatively large numbers of patients receiving risperidone in this naturalistic study, no serious side-effects were reported or identified. In this paper we focus our findings on antipsychotics in the light of recent advice from the Committee on Safety of Medicines (UK).     

Schizoaffective disorder: a form of schizophrenia or affective disorder?

BACKGROUND: The diagnostic status of schizoaffective disorder continues to be controversial. Researchers have proposed that schizoaffective disorder represents a variant of schizophrenia or affective disorder, a combination of the 2, or an intermediate condition along a continuum between schizophrenia and affective disorder. METHOD: We compared outpatients aged 45 to 77 years with DSM-III-R diagnosis of schizoaffective disorder (N = 29), schizophrenia (N = 154), or nonpsychotic mood disorder (N = 27) on standardized rating scales of psychopathology and a comprehensive neuropsychological test battery. A discriminant function analysis was used to classify the schizoaffective patients based on their neuropsychological profiles as being similar either to schizophrenia patients or to those with nonpsychotic mood disorder. RESULTS: The schizoaffective and schizophrenia patients had more severe dyskinesia, had a weaker family history of mood disorder, had been hospitalized for psychiatric reasons more frequently, were more likely to be prescribed neuroleptic and anticholinergic medication, and had somewhat less severe depressive symptoms than the mood disorder patients. The schizophrenia patients had more severe positive symptoms than the schizoaffective and mood disorder patients. The neuropsychological performances of the 2 psychosis groups were more impaired than those of the nonpsychotic mood disorder patients. Finally, on the basis of a discriminant function analysis, the schizoaffective patients were more likely to be classified as having schizophrenia than a mood disorder. CONCLUSION: These findings suggest that schizoaffective disorder may represent a variant of schizophrenia in clinical symptom profiles and cognitive impairment.     

Co-occurrence of HIV and serious mental illness among Medicaid recipients

OBJECTIVE: The authors estimated the treated period prevalence of HIV infection in the Medicaid population and the rate of HIV infection among persons with serious mental illness in that population. METHODS: This cross-sectional study used Medicaid claims data and welfare recipient files for persons aged 18 years or older for fiscal years 1994 through 1996 in Philadelphia. Claims data were merged with welfare recipient files to calculate the treated period prevalence of serious mental illness, defined as a schizophrenia spectrum disorder or a major affective disorder, and HIV infection in the Medicaid population and the odds of receiving a diagnosis of HIV infection among those who had a diagnosis of serious mental illness. RESULTS: The treated period prevalence of HIV infection was.6 percent among Medicaid recipients who did not have a diagnosis of a serious mental illness and 1.8 percent among those who did. After sex, age, race, and time on welfare during the study period were controlled for, patients with a schizophrenia spectrum disorder were 1.5 times as likely to have a diagnosis of HIV infection, and patients with a diagnosis of a major affective disorder were 3.8 times as likely. CONCLUSIONS: The rate of HIV infection is significantly elevated among persons with serious mental illness. Further studies are needed to determine modes of transmission of HIV, special treatment needs, and effective strategies for reducing the risk of HIV infection.     

Major self-mutilation in the first episode of psychosis

Major self-mutilation (MSM) is a rare but catastrophic complication of severe mental illness. Most people who inflict MSM have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, MSM is most likely to occur. In this study, the proportion of patients in first episode of psychosis (FEP) was assessed using the results of a systematic review of published case reports. Histories of patients who had removed an eye or a testicle, severed their penis, or amputated a portion of a limb and were diagnosed with a schizophrenia spectrum psychosis were included. A psychotic illness was documented in 143 of 189 cases (75.6%) of MSM, of whom 119 of 143 (83.2%) were diagnosed with a schizophrenia spectrum psychosis. The treatment status of a schizophrenia spectrum psychosis could be ascertained in 101 of the case reports, of which 54 were in the FEP (53.5%, 95% confidence interval = 43.7%-63.2%). Patients who inflict MSM in FEP exhibited similar symptoms to those who inflict MSM later in their illness. Acute psychosis, in particular first-episode schizophrenia, appears to be the major cause of MSM. Although MSM is extremely uncommon, earlier treatment of psychotic illness may reduce the incidence of MSM.     

Increased risk for metabolic syndrome in persons seeking care for mental disorders.

BACKGROUND: An increased risk for metabolic syndrome has been described for persons with psychotic and mood disorders. Our objectives were to determine whether the odds for metabolic syndrome (MetSyn) were increased among insured adults with and without mental illness, and to determine whether this risk extends beyond psychotic and affective disorders. METHOD: This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa claims data. Three definitions of MetSyn were examined: 1) presence of any 3 or more components of MetSyn (obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus), 2) criteria #1 and/or claim for glucose intolerance/diabetes mellitus, and 3) criteria #1, criteria #2, and/or claim for obesity. ICD-9 codes were used to define obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus. Multivariate logistic regression was used to investigate the association between mental illness and MetSyn. RESULTS: Prevalence of MetSyn for subjects with any mental illness as compared to those without was 4.9% vs. 2.0% (criteria #1), 8.1% vs. 4.2% (criteria #2), and 13.2% vs. 6.2% (criteria #3). MetSyn was more common (OR = 1.3-1.5) for subjects with any mental illness as compared to those without, regardless of which definition of MetSyn was used. Subjects with sexual disorders (OR = 1.7-1.8), sleep disorders (OR = 1.2-1.7), and mood disorders (OR = 1.3-1.6) had significantly higher odds of MetSyn compared to those without claims for mental disorders, regardless of which definition of MetSyn was used. CONCLUSIONS: These results suggest that MetSyn is not only problematic among persons with psychosis and affective disorders, but that it also affects patients with other forms of mental illness. Clinicians should have a heightened awareness of metabolic risk factors, particularly when mental illness is present.     

Risk behaviors for sexually transmitted infections among men with mental disorders

OBJECTIVE: Risk behaviors for sexually transmitted infections among men with mental disorders who were using outpatient psychiatric services and among men who had never been treated for a mental disorder were compared. METHODS: Ninety-two men with major mental disorders, including schizophrenia, bipolar disorder, and mood disorders, were individually matched for age and ethnicity with 92 men who had never been treated for mental illness. All subjects completed a semistructured interview about specific risk behaviors for sexually transmitted infections that they may have engaged in during the preceding year. RESULTS: The 49 patients with mental disorders who had been sexually active in the preceding year were significantly more likely than the 78 sexually active comparison subjects to have known their sexual partner for less than one day and to report having been pressured into unwanted sexual intercourse. A strong but not significant trend was found for sexually active patients to have had sex with a male partner and sex with a drug user. Overall, the patients with mental disorders answered ten questions measuring AIDS knowledge questions significantly less well than the comparison subjects. CONCLUSIONS: The results underscore the priority for developing programs for preventing risk behaviors for sexually transmitted infections among men with mental disorders.     

Gender differences in cognitive deficits in schizophrenia with and without diabetes

This study investigated gender differences in cognition in schizophrenia with and without diabetes. Cognition was assessed in 263 individuals with schizophrenia with age range (40–68): 67 males and 34 females with schizophrenia with diabetes; and 125 males and 37 females with schizophrenia without diabetes according to the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Fasting glucose, hemoglobin A1c (HbA1c) and lipid levels were measured. Results showed that male individuals performed worse on most cognitive tasks, especially attention, in schizophrenia with than without diabetes. This result was not observed in female individuals. Also, individuals of both genders showed higher fasting glucose and HbA1c in schizophrenia with than without diabetes. In schizophrenia with diabetes, males had significantly worse cognition than females in all cognitive domains. Higher HbA1c, lower high-density lipoprotein, and an earlier age of onset of schizophrenia were found in males compared with female individuals. HbA1c was negatively associated with attention and the RBANS total score for males but not for females. In schizophrenia without diabetes, males showed worse performance in immediate and delayed memory than females. This study support cognition was worse for males with schizophrenia irrespective of whether they have diabetes. However, diabetes exemplified the gender differences, especially in attention.