Metabolic syndrome in patients with schizophrenia

BACKGROUND: Our aim was to study the frequency of metabolic syndrome and associated factors in patients with schizophrenia. METHOD: The study group consisted of 35 outpatients with long-term schizophrenia defined by DSM-IV criteria. Patients were assessed for the presence of metabolic syndrome, which was defined by the criteria of the National Cholesterol Education Program. All patients were on antipsychotic medication. Data were collected from Jan. 1, 2001, to Aug. 30, 2001. RESULTS: Metabolic syndrome was found in 37% (N = 13) of the patients, and it was associated inversely with the total daily dose of, but not with any specific type of, antipsychotic drug. CONCLUSION: The results suggest that metabolic syndrome is common among patients with schizophrenia, and it may be far more common than in general populations.     

The risk of metabolic syndrome among institutionalized adults with intellectual disabilities

People with metabolic syndrome (MS) are at increased risk of coronary heart disease and other health problems, such as diabetes and stroke. However, there is little previous information on the prevalence and determinants of MS among people with intellectual disabilities (IDs). The present study aimed to examine the prevalence of MS risk factors among institutionalized adults with IDs. We analyzed the annual health check data of 164 institutionalized adults with IDs whose age was ≧20 years in 2009. The measure of MS in the study was the presence of three or more of the following five components: central obesity, elevated blood pressure (BP), elevated fasting glucose (FG), elevated triglycerides (TG), and reduced high-density lipoprotein (HDL-C). The prevalence of MS was 11.6% in the study participants (8% in males and 17.2% in females), which is lower than that in the general population of Taiwan. In the logistic regression analysis of the occurrence of MS, we found that gender, TG and HDL-C were variables that could significantly predict MS after controlling for other potential factors. Adults with IDs who were female (OR = 38.354, 95% CI = 1.985-741.029) and who had higher TG levels (OR = 1.043, 95% CI = 1.008-1.079) and reduced HDL-C levels (OR = 0.696, 95% CI = 0.549-0.883) had a statistically higher risk of MS. This study was one of the first to provide information on the prevalence of MS and its risk factors among institutionalized adults with IDs. We suggest that further study should focus on the specifics of MS, such as incidence, age-specific risk factors and further prevention or treatment in people with ID.     

Serious cardiovascular events and mortality among patients with schizophrenia

This study compared the risks of cardiovascular morbidity and mortality in people with schizophrenia who use antipsychotic medications to risks in individuals without schizophrenia in a large managed care organization. A sample of 1920 schizophrenia patients was matched by age, sex, date, and health plan to 9600 persons randomly selected from the health plan general membership. Death, myocardial infarction, arrhythmia, and new-onset diabetes were identified using a National Death Index search and medical claims records.The adjusted all-cause mortality rate in the group of treated schizophrenics was four times higher than in the control group regardless of whether patients were given a typical or an atypical antipsychotic medication. Users of typical antipsychotics had a fivefold higher risk of myocardial infarction than the control subjects. Among patients with schizophrenia, cardiovascular risk was inversely associated with intensity of use of antipsychotic drugs, suggesting that the observed risks may not be due to a simple or direct effect of drugs. Patients treated for schizophrenia had higher rates of new-onset diabetes than did the general population controls. This risk was most pronounced in persons with more intense exposure to drugs and appeared to be indistinguishable in users of typical antipsychotics, of atypical products, or of both.     

Metabolic risk during antipsychotic treatment in patients with schizophrenia

Compared with the general population, persons with schizophrenia are characterized with an increased prevalence of obesity, type 2 diabetes mellitus, and cardiovascular disease. Weight gain and increased adiposity is associated with decreases in insulin sensitivity, leading to an increased risk of hyperglycaemia and hyperlipidemia. Antipsychotic drugs can increase adiposity and the range of trials suggests that treatment with antipsychotic medications may be associated with an increased risk of acute (ketoacidosis), subacute (weight gain, glucose intolerance, insulin resistance, dyslipidemia), and chronic (diabetes, hypertension, coronary heart disease) metabolic complications. Conclusions regarding the relative effects of various antipsychotic agents on different components of the metabolic syndrome were reviewed, as well as recommendations for monitoring these effects were noted. Selection and management of the antipsychotic agent reflects a balance between optimizing therapeutic effectiveness, modifying diet and exercise, and avoiding excessive weight gain, dyslipidemia, and insulin resistance.     

Adjunctive divalproex and hostility among patients with schizophrenia receiving olanzapine or risperidone

OBJECTIVE: This study compared the specific antihostility effects of atypical antipsychotic monotherapy (olanzapine or risperidone) with that of combination treatment with divalproex sodium among patients with schizophrenia experiencing an acute psychotic episode. METHODS: A total of 249 inpatients with schizophrenia were randomly assigned to receive olanzapine plus placebo, olanzapine plus divalproex, risperidone plus placebo, or risperidone plus divalproex in a double-blind, 28-day multicenter trial. The target daily dose was 15 milligrams for olanzapine, 6 milligrams for risperidone, and up to 30 milligrams per kilogram (minimum, 15 milligrams per kilogram) for divalproex. The hostility item of the Positive and Negative Syndrome Scale (PANSS) was the principal outcome measure. Covariates included the PANSS items reflecting positive symptoms of schizophrenia (delusions, suspiciousness/persecution, grandiosity, unusual thought content, conceptual disorganization, and hallucinatory behavior). RESULTS: Combination treatment with risperidone or olanzapine plus divalproex was associated with different scores on the hostility item of the PANSS compared with antipsychotic monotherapy. Combination therapy had a significantly greater antihostility effect at days 3 and 7 than monotherapy. This result was not seen beyond the first week of treatment, but there was a trend toward a difference in effect for the entire treatment period. The effect on hostility appears to be statistically independent of antipsychotic effect on other PANSS items reflecting delusional thinking, a formal thought disorder, or hallucinations. CONCLUSIONS: Divalproex sodium may be useful as an adjunctive agent in specifically reducing hostility in the first week of treatment with risperidone or olanzapine among patients with schizophrenia experiencing an acute psychotic episode.     

Increased suicidal risk among smoking schizophrenia patients

INTRODUCTION: Schizophrenia patients display a high suicidal risk, although this risk is difficult to predict. One of the variables associated with increased suicide risk is smoking. In the present study, we assessed the suicidal risk in schizophrenia patients, smokers and nonsmokers. We also evaluated the impact of various variables such as psychotic symptoms, impulsivity, and extra-pyramidal side effects on suicidal risk. METHODS: Sixty-one schizophrenia patients responded to a battery of measures, including the suicidal risk scale (SRS), the positive and negative syndrome scale (PANSS), the impulsivity control scale, and the Simpson Angus Scale for extrapyramidal side effects. The effect of smoking on the various measures, especially suicidal risk, was examined. RESULTS: Schizophrenia patients who smoke obtained higher PANSS scores (both total score and positive and negative subscales), but did not differ on the Simpson Angus scale of extrapyramidal side effects. They also exhibited higher suicide risk as reflected by higher scores on the SRS, and a trend for higher impulsivity as measured by the impulsivity control scale. Women that smoked had higher SRS scores as compared with female nonsmokers, and also higher than in males, smokers and nonsmokers. Smoking and a history of suicide attempt predicted in our regression analysis a higher SRS score. When conducting separate analyses for the male and female patients, the significant contributors were the PANSS total score among the males and the number of pack-years among the female patients. CONCLUSIONS: Despite hints toward the role of smoking in suicidal behavior in Schizophrenia, especially among female patients, more studies are needed to elucidate the association between smoking and suicidality in schizophrenia patients.     

Clock drawing test in institutionalized patients with schizophrenia compared with Alzheimer's disease patients

The impaired performance of Alzheimer's disease (AD) patients on the clock drawing test (CDT) relative to age-matched normal controls is a well-documented finding in the literature. On the other hand, there is sparse information regarding the use of this test in schizophrenia. We examined three groups of subjects matched for gender and education: institutionalized patients with schizophrenia (n = 32), patients with AD (n = 32), and normal controls (n = 36). The CDT ("free-drawn", "pre-drawn", and three "examiner" conditions) and Mini-Mental State Examination (MMSE) were administered to all participants. In patients with schizophrenia, symptom severity was assessed with the Brief Psychiatric Rating Scale (BPRS). Patients with schizophrenia were significantly younger than AD patients and normal controls (56.78 versus 71.41 and 66.25, respectively), and normal controls had significantly higher MMSE scores than patients with schizophrenia and AD (27.58 versus 20.75 and 18.44, respectively). In all of the clock conditions, the two patient groups performed significantly poorer than the normal controls, with the exception of the "pre-drawn" clock in which AD patients also performed worse than patients with schizophrenia. Age and duration of illness did not correlate significantly with CDT scores. When MMSE scores were used as a covariate, all significant differences on the CDT among the three groups disappeared, with the exception of the "pre-drawn" clock (AD patients had lower scores than both control and schizophrenia groups). In patients with schizophrenia, scores on the BPRS were not related with any CDT variable. Institutionalized patients with schizophrenia and AD patients showed similar deficits on a neuropsychological test sensitive to changes in visual-analytic function, attention, receptive language, and executive functions such as planning, organization, and simultaneous processing.     

Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia

OBJECTIVE: The objective of this study was to evaluate the relationship between compliance with an antipsychotic medication regimen and risk of hospitalization in a cohort of California Medicaid patients with schizophrenia. METHODS: Compliance behavior was estimated by using a retrospective review of California Medicaid pharmacy refill and medical claims for 4,325 outpatients for whom antipsychotics were prescribed for treatment of schizophrenia from 1999 to 2001. Compliance behavior was estimated by using four different definitions: gaps in medication therapy, medication consistency and persistence, and a medication possession ratio. Patients were followed for one year and had an average of 19.1 dispensing events. Logistic regression models using each compliance estimate were used to determine the odds of hospitalization. RESULTS: Risk of hospitalization was significantly correlated with compliance. With all definitions, lower compliance was associated with a greater risk of hospitalization over and above any other risk factors for hospitalization. For example, the presence of any gap in medication coverage was associated with increased risk of hospitalization, including gaps as small as one to ten days (odds ratio [OR]=1.98). A gap of 11 to 30 days was associated with an OR of 2.81, and a gap of more than 30 days was associated with an OR of 3.96. CONCLUSIONS: This study showed a direct correlation between estimated partial compliance and hospitalization risk among patients with schizophrenia across a continuum of compliance behavior.     

Metabolic syndrome among Chinese obese patients with epilepsy on sodium valproate

BackgroundMany publications have addressed the problem of weight gain and endocrine abnormalities in patients treated with sodium valproate (VPA). However, the presence of metabolic syndrome (MetS) among obese patients with epilepsy on VPA has received little attention.MethodsThirty-six patients receiving VPA monotherapy were included in this study to evaluate the presence of MetS. All patients were interviewed and clinically examined. Blood samples were obtained after an overnight fast, and an oral glucose-tolerance test was performed. Twenty-eight subjects who were obese but had no epilepsy and were otherwise well were collected as controls (“simple obesity” group).ResultsThe two study groups were well matched in terms of age, gender and body mass index. Insulin resistance measured via homeostasis model assessment (HOMA) index was more severe among the VPA-treated group (4.91 ± 2.91 vs. 2.00 ± 1.72, P = 0.007). The frequency of the MetS was slightly higher in the patients with epilepsy compared to controls (47.2% vs. 32.1%, respectively), but this difference was not statistically significant (P = 0.223). Multivariate analysis with stepwise logistic regression revealed low positive correlations between MetS development, HOMA index (P = 0.029; r = 0.361) and valproic acid dose (P = 0.049; r = 0.323). These correlations were independent of other clinical parameters.ConclusionsOur preliminary study suggests that obese patients with epilepsy treated with VPA are at higher risk of MetS than individuals who are “simply obese” but otherwise well. Therefore, the HOMA index should be monitored in obese patients who receive VPA therapy, rather than monitoring body weight alone.     

Verbal fluency in institutionalized patients with schizophrenia: age-related performance decline

Several studies have reported a relatively stable level of cognitive deficits among patients with schizophrenia regardless of age, while others have suggested continued deterioration with age. We compared the performance of 42 institutionalized patients with schizophrenia and 42 age- and education-matched healthy controls on a semantic and phonemic verbal fluency test. Each group was divided into young participants (<65 years old) and elderly participants (> or =65 years old). We found a fluency condition x diagnostic group x age group interaction on total words produced, a fluency condition x diagnostic group interaction on the number of cluster-related words, and a fluency condition x age group interaction on the number of switches. Patients with schizophrenia generally used similar strategies (i.e., semantic or phonemic cluster-related words and switches) as healthy individuals when generating words, but to a lesser degree. We found a disproportionate decline in the elderly schizophrenic patients relative to that of healthy controls only on the phonemic, relative to the semantic test. This decline in performance appears related to the effects of aging rather than severity or chronicity of illness, duration of institutionalization, or a progressive degenerative process associated with the disorder.     

Suicide attempts of schizophrenia patients: a case-controlled study in tertiary care

BACKGROUND: Schizophrenia is one of the disorders in which suicide attempts and death by suicide are pronounced. However, there is paucity of data regarding suicide attempts by schizophrenia patients. The aim of the present study was to characterize a large sample of schizophrenia patients in tertiary care who had attempted suicide. METHOD: Over a 15-year period all computerized records of admissions of adult schizophrenia patients were examined. Patients who had attempted suicide were defined as the index group and the comparison group was comprised of the next admission of a patient suffering from schizophrenia who did not attempt suicide prior to hospitalization. RESULTS: There were 10,006 admissions of patients suffering from schizophrenia during the study period. Of these, 1094 (10.9%) records comprise the index group (patients who had attempted suicide), 380 women and 714 men, mean age for the group 39.6+/-12.9 years. The comparison group of patients matched for diagnosis (N=1094), consisted of 302 women and 792 men, mean age for this group was 42.9+/-13.7 years. Four variables significantly differentiated between groups. Patients who had attempted suicide were younger (39.6 vs. 42.9 years; p=0.00), higher percentage of females (34.7% vs. 27.6%; p=0.00), with increased rates of co-morbid physical illness (27.5% vs. 20.4%; p=0.00) notably cardiovascular and diabetes and with a higher rate of alcohol and drug abuse (32.1% vs. 12.4%; p=0.00). CONCLUSIONS: The present study emphasizes several significant factors associated with attempted suicide amongst schizophrenia patients notably physical co-morbidity and abuse of alcohol and drugs. These need be integrated into existing risk assessment schemes thus aiding in decreasing adverse outcomes in this vulnerable group of patients.     

Pharmacotherapy and health care costs among patients with schizophrenia and newly diagnosed diabetes

OBJECTIVE: This study investigated how antipsychotic pharmacotherapy and health care costs change after diabetes mellitus is newly diagnosed among patients with schizophrenia. METHODS: Administrative data from the Department of Veterans Affairs were retrospectively reviewed to examine patients with schizophrenia who did not have any history of diabetes and for whom a consistent regimen of antipsychotic monotherapy was prescribed for any three-month period between June 1999 and September 2000. Data for these patients were reviewed through September 2001. Patients who were given a new diagnosis of diabetes were identified, along with a matched comparison group of patients who were not given a diagnosis of diabetes. Medication changes and costs were compared between patients with diabetes and those without and between patients who were taking second-generation antipsychotics and those who were taking first-generation antipsychotics. RESULTS: Of the 56,849 patients who fit the criteria for the study, 4,132 (7.3 percent) were subsequently given a diagnosis of diabetes (7.4 percent were taking second-generation antipsychotics and 7.1 percent were taking first-generation antipsychotics). Differences in the proportions of patients with and without diabetes who switched or discontinued antipsychotics were small and were statistically significant only for patients who were taking risperidone before the diabetes diagnosis date. The average marginal cost of treating a patient with diabetes was 3,104 US dollars over an average follow-up of 15.7 months, or 6.59 US dollars per day. Because the attributable risks of diabetes with second-generation antipsychotics averaged .875 percent, the average additional daily cost per patient that was attributable to each second-generation medication was small, ranging from .003 US dollars for risperidone to .134 US dollars for clozapine. CONCLUSIONS: Surprisingly, a new diagnosis of diabetes did not result in substantial antipsychotic medication changes, even among patients who were taking clozapine or olanzapine. Even though the costs of treating patients with newly diagnosed diabetes were substantial, the increased costs attributable to second-generation antipsychotics were small.     

Cognitive impairment and functional status in elderly institutionalized patients with schizophrenia.

OBJECTIVE: The relationship of cognitive impairment to functional status in older adults with schizophrenia was investigated. PATIENTS: Ninety-three psychiatric inpatients with schizophrenia between the ages of 65 and 88 years. Two subsets of this sample, consisting of 48 and 24 patients, were studied with a greater number of assessment instruments. MEASURES: The Mini-Mental State Examination (MMSE) was used for brief assessment of overall cognitive functioning, and the Psychogeriatric Dependency Rating Scale (PGDRS) was administered to assess functional status. The cognitive test battery from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) and/or an expanded neuropsychological battery, was given to a subset of the patients. RESULTS: In the overall sample, patients with greater global cognitive impairment had higher levels of rated impairment on the individual items that comprised the Orientation and Physical, but not Behavior, subscales of the PGDRS. Furthermore, in the two subsamples, specific neuropsychological measures of problem-solving, word list learning, naming and constructional praxis were related to overall measures of outcome. CONCLUSIONS: Neuropsychological deficit and psychosocial outcome are multi-dimensional entities that relate to one another in complex ways.