Exercise can improve clinical outcomes in people with severe mental illness (SMI). However, this population typically engages in low levels of physical activity with poor adherence to exercise ...interventions. Understanding the motivating factors and barriers towards exercise for people with SMI would help to maximize exercise participation. A search of major electronic databases was conducted from inception until May 2016. Quantitative studies providing proportional data on the motivating factors and/or barriers towards exercise among patients with SMI were eligible. Random-effects meta-analyses were undertaken to calculate proportional data and 95% confidence intervals (CI) for motivating factors and barriers toward exercise. From 1468 studies, 12 independent studies of 6431 psychiatric patients were eligible for inclusion. Meta-analyses showed that 91% of people with SMI endorsed ‘improving health’ as a reason for exercise (N = 6, n = 790, 95% CI 80–94). Among specific aspects of health and well-being, the most common motivations were ‘losing weight’ (83% of patients), ‘improving mood’ (81%) and ‘reducing stress’ (78%). However, low mood and stress were also identified as the most prevalent barriers towards exercise (61% of patients), followed by ‘lack of support’ (50%). Many of the desirable outcomes of exercise for people with SMI, such as mood improvement, stress reduction and increased energy, are inversely related to the barriers of depression, stress and fatigue which frequently restrict their participation in exercise. Providing patients with professional support to identify and achieve their exercise goals may enable them to overcome psychological barriers, and maintain motivation towards regular physical activity.
Objective
To review recent advances in the epidemiology, pathobiology, and management of weight gain and obesity in patients with schizophrenia and to evaluate the extent to which they should ...influence guidelines for clinical practice.
Method
A Medline literature search was performed to identify clinical and experimental studies published in 2005–2014 decade.
Results
Weight gain and obesity increase the risk of adult‐onset diabetes mellitus and cardiovascular disorders, non‐adherence with pharmacological interventions, quality of life, and psychiatric readmissions. The etiology includes adverse effects of antipsychotics, pretreatment/premorbid genetic vulnerabilities, psychosocial and socioeconomic risk factors, and unhealthy lifestyle. Patients with schizophrenia have higher intake of calories in the form of high‐density food and lower energy expenditure. The inverse relationship between baseline body mass index and antipsychotic‐induced weight gain is probably due to previous antipsychotic exposure. In experimental models, the second‐generation antipsychotic olanzapine increased the orexigenic stimulation of hypothalamic structures responsible for energy homeostasis.
Conclusion
The management of weight gain and obesity in patients with schizophrenia centers on behavioural interventions using caloric intake reduction, dietary restructuring, and moderate‐intensity physical activity. The decision to switch antipsychotics to lower‐liability medications should be individualized, and metformin may be considered for adjunctive therapy, given its favorable risk‐benefit profile.
Objective
To conduct a meta‐analysis investigating the prevalence of type two diabetes mellitus (T2DM) in people with schizophrenia compared to controls.
Method
Systematic review of electronic ...databases from inception till November 2014. Articles reporting the prevalence of T2DM in people with schizophrenia and healthy controls (without mental illness) were included. Two independent authors conducted searches and extracted data. A random effects relative risks (RR) meta‐analysis was conducted.
Results
Twenty‐five studies including 145 718 individuals with schizophrenia (22.5–54.4 years) and 4 343 407 controls were included. The prevalence of T2DM in people with schizophrenia was 9.5% (95% CI = 7.0–12.8, n = 145 718) and 10.75% (95% CI 7.44–14.5%, n = 2698) in studies capturing T2DM according to recognized criteria. The pooled RR across all studies was 1.82 (95% CI = 1.56–2.13; = 4 489 125). Subgroup analyses found a RR of 2.53 (95% CI = 1.68–3.799, n = 17 727) in studies ascertaining T2DM according to recognized criteria and RR 1.65 (95% CI = 1.34–2.03, n = 4 243 389) in studies relying on T2DM determined through medical records.
Conclusion
People with schizophrenia are at least double the risk of developing T2DM according to recognized T2DM criteria. Proactive lifestyle and screening programmes should be given clinical priority.
Depression and pain are leading causes of global disability. However, there is a paucity of multinational population data assessing the association between depression and pain, particularly among ...low- and middle-income countries (LMICs) where both are common. Therefore, we investigated this association across 47 LMICs.
Community-based data on 273 952 individuals from 47 LMICs were analysed. Multivariable logistic and linear regression analyses were performed to assess the association between the International Classification of Diseases, 10th Revision depression/depression subtypes (over the past 12 months) and pain in the previous 30 days based on self-reported data. Country-wide meta-analysis adjusting for age and sex was also conducted.
The prevalence of severe pain was 8.0, 28.2, 20.2, and 34.0% for no depression, subsyndromal depression, brief depressive episode, and depressive episode, respectively. Logistic regression adjusted for socio-demographic variables, anxiety and chronic medical conditions (arthritis, diabetes, angina, asthma) demonstrated that compared with no depression, subsyndromal depression, brief depressive episode, and depressive episode were associated with a 2.16 95% confidence interval (CI) 1.83-2.55, 1.45 (95% CI 1.22-1.73), and 2.11 (95% CI 1.87-2.39) increase in odds of severe pain, respectively. Similar results were obtained when a continuous pain scale was used as the outcome. Depression was significantly associated with severe pain in 44/47 countries with a pooled odds ratio of 3.93 (95% CI 3.54-4.37).
Depression and severe pain are highly comorbid across LMICs, independent of anxiety and chronic medical conditions. Whether depression treatment or pain management in patients with comorbid pain and depression leads to better clinical outcome is an area for future research.
Objective
Physical activity (PA) is good for health, yet several small‐scale studies have suggested that depression is associated with low PA. A paucity of nationally representative studies ...investigating this relationship exists, particularly in low‐ and middle‐income countries (LMICs). This study explored the global association of PA with depression and its mediating factors.
Method
Participants from 36 LMICs from the World Health Survey were included. Multivariable logistic regression analyses were undertaken exploring the relationship between PA and depression.
Results
Across 178 867 people (mean ± SD age = 36.2 ± 13.5 years; 49.9% male), the prevalence of depression and the prevalence of low PA were 6.6% and 16.8% respectively. The prevalence of low PA was significantly higher among those with depression vs. no depression (26.0% vs. 15.8%, P < 0.0001). In the adjusted model, depression was associated with higher odds for low PA (OR = 1.42; 95% CI = 1.24–1.63). Mediation analyses demonstrated that low PA among people with depression was explained by mobility limitations (40.3%), pain and discomfort (35.8%), disruptions in sleep and energy (25.2%), cognition (19.4%) and vision (10.9%).
Conclusion
Individuals with depression engage in lower levels of PA in LMICs. Future longitudinal research is warranted to better understand the relationships observed.
Vancampfort D, Knapen J, Probst M, Scheewe T, Remans S, De Hert M. A systematic review of correlates of physical activity (PA) in patients with schizophrenia.
Objective: The present review evaluates ...systematically the published quantitative studies of correlates of PA in patients with schizophrenia.
Method: EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL and PEDro were searched from their inception to 1 July 2011 combining the medical subject heading ‘schizophrenia’ with ‘physical activity’ or ‘physical inactivity’ or ‘exercise’ or ‘health education’ or ‘health behaviour’ or ‘health promotion’.
Results: Out of 68 potentially eligible studies, 25 papers (n = 25 013) evaluating 36 correlates were included. Correlates consistently associated with lower PA participation are the presence of negative symptoms and cardio‐metabolic comorbidity. Also, side‐effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self‐efficacy, other unhealthy lifestyle habits and social isolation correlated with lower PA participation. The quality of the PA measurement was not related to the proportion of significant associations (χ2 = 3.8, P = 0.07). Current gaps in literature that need to be examined more in detail are the role of environmental and policy‐level factors on PA participation in patients with schizophrenia.
Conclusion: All correlates should be confirmed in prospective studies, and interventions to improve the modifiable variables should be developed and evaluated.
We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic ...medication (AP).
A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP.
In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100 mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE.
There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.
Individuals with depression have an elevated risk of cardiovascular disease (CVD) and metabolic syndrome (MetS) is an important risk factor for CVD. We aimed to clarify the prevalence and correlates ...of MetS in persons with robustly defined major depressive disorder (MDD).
We searched Medline, PsycINFO, EMBASE and CINAHL up until June 2013 for studies reporting MetS prevalences in individuals with MDD. Medical subject headings 'metabolic' OR 'diabetes' or 'cardiovascular' or 'blood pressure' or 'glucose' or 'lipid' AND 'depression' OR 'depressive' were used in the title, abstract or index term fields. Manual searches were conducted using reference lists from identified articles.
The initial electronic database search resulted in 91 valid hits. From candidate publications following exclusions, our search generated 18 studies with interview-defined depression (n = 5531, 38.9% male, mean age = 45.5 years). The overall proportion with MetS was 30.5% 95% confidence interval (CI) 26.3-35.1 using any standardized MetS criteria. Compared with age- and gender-matched control groups, individuals with MDD had a higher MetS prevalence odds ratio (OR) 1.54, 95% CI 1.21-1.97, p = 0.001. They also had a higher risk for hyperglycemia (OR 1.33, 95% CI 1.03-1.73, p = 0.03) and hypertriglyceridemia (OR 1.17, 95% CI 1.04-1.30, p = 0.008). Antipsychotic use (p < 0.05) significantly explained higher MetS prevalence estimates in MDD. Differences in MetS prevalences were not moderated by age, gender, geographical area, smoking, antidepressant use, presence of psychiatric co-morbidity, and median year of data collection.
The present findings strongly indicate that persons with MDD are a high-risk group for MetS and related cardiovascular morbidity and mortality. MetS risk may be highest in those prescribed antipsychotics.
Objective
Cardiorespiratory fitness (CRF) is a major modifiable risk factor for cardiovascular disease (CVD). We conducted a clinical overview to highlight the reduced CRF expressed as maximal oxygen ...uptake (VO2max) (or predicted) or peak oxygen uptake (VO2peak) in people with schizophrenia compared to the general population. We also aimed to identify correlates of and clinical strategies to improve CRF.
Method
We systematically searched major electronic databases from inception until November 2014. A meta‐analysis calculating the standardised mean difference (SMD) was employed.
Results
CRF was significantly reduced in people with schizophrenia (n = 154) with a SMD of −0.96 (95% CI −1.29 to −0.64) (N = 5) compared to controls (n = 182). Negative symptoms, increased body mass index and female gender were negatively associated with CRF. Promoting physical activity may improve CRF in people with schizophrenia by up to 4–4.5 ml/kg/min following a 6–8 weeks programme (N = 4, n = 98).
Conclusion
People with schizophrenia have a large and significantly reduced CRF. Given the overwhelming evidence for physical activity as the cornerstone of preventing and managing CVD in the general population, incorporating such interventions in the treatment of people with schizophrenia is justified and urgently required. We present clear practical strategies of how this can be achieved within clinical settings.
Despite increased cardiometabolic risk in individuals with mental illness taking antipsychotic medication, metabolic screening practices are often incomplete or inconsistent.
We undertook a ...systematic search and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) meta-analysis of studies examining routine metabolic screening practices in those taking antipsychotics both for patients in psychiatric care before and following implementation of monitoring guidelines.
We identified 48 studies (n=290 534) conducted between 2000 and 2011 in five countries; 25 studies examined predominantly schizophrenia-spectrum disorder populations; 39 studies (n=218 940) examined routine monitoring prior to explicit guidelines; and nine studies (n=71 594) reported post-guideline monitoring. Across 39 studies, routine baseline screening was generally low and above 50% only for blood pressure 69.8%, 95% confidence interval (CI) 50.9-85.8 and triglycerides (59.9%, 95% CI 36.6-81.1). Cholesterol was measured in 41.5% (95% CI 18.0-67.3), glucose in 44.3% (95% CI 36.3-52.4) and weight in 47.9% (95% CI 32.4-63.7). Lipids and glycosylated haemoglobin (HbA1c) were monitored in less than 25%. Rates were similar for schizophrenia patients, in US and UK studies, for in-patients and out-patients. Monitoring was non-significantly higher in case-record versus database studies and in fasting samples. Following local/national guideline implementation, monitoring improved for weight (75.9%, CI 37.3-98.7), blood pressure (75.2%, 95% CI 45.6-95.5), glucose (56.1%, 95% CI 43.4-68.3) and lipids (28.9%, 95% CI 20.3-38.4). Direct head-to-head pre-post-guideline comparison showed a modest but significant (15.4%) increase in glucose testing (p=0.0045).
In routine clinical practice, metabolic monitoring is concerningly low in people prescribed antipsychotic medication. Although guidelines can increase monitoring, most patients still do not receive adequate testing.
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