Knowledge & Library Services: Search results

Searcher: Caroline De Brún (caroline.debrun@phe.gov.uk)

Person requesting search: Martin R White (Martin.R.White@phe.gov.uk)

Date of request: 14/11/2018 Date results sent: 14/12/18 Revised: 23/01/19

Level of search: 1) bibliography

Revised results to include "metabolic syndrome":

Bordin, P., Picco, F., Valent, F., et al. 2018. Cardiovascular prevention in 50-year-old adults: An Italian intervention study. Journal of Cardiovascular Medicine 19(8) 422-429.

Aims Cardio50 is a project of active risk identification and cardiovascular prevention implemented in an Italian cohort of healthy people aged 50. Methods A total of 3127 individuals were invited for a screening visit with lifestyle interview and registration of BMI, blood pressure (BP), glucose, cholesterol and classified into groups: A (normal), B (abnormal lifestyle, normal parameters), C (at least one abnormal parameter). People in group C were offered a free blood test and a specialistic medical visit to investigate the suspect of hypertension, dyslipidemia or dysglycemia. Those in groups B and C were scheduled for a follow-up visit after 4-6 months and finally readdressed to the general practitioner. Results A total of 2325 invited individuals attended the screening visit: 18% were classified in group A, 32% in B, 42% in C, 8% met exclusion criteria and were not classifiable. In group C, 86% attended to the cardiologist visit, 76% had dyslipidemia, 35% hypertension, 1% diabetes, 14% impaired fasting glycemia, 19% obesity, 21% metabolic syndrome; 21% were smokers, 11% at risk of alcoholism. At follow-up, we appreciated a decrease in BP in group C individuals. After lifestyle intervention, physical activity increased, whereas metabolic syndrome, impaired fasting glucose and risky drinking decreased. Conclusion The current project is coherent with modern strategies based on multifactorial actions. After the intervention, we observed an early reduction in BP and some improvements in lifestyle. This simple and low-technology program allowed us to detect and treat large numbers of individuals at high risk for cardiovascular events. Copyright © 2018 Italian Federation of Cardiology. All rights reserved.

Butnoriene, J., Steibliene, V., Saudargiene, A., et al. 2018. Does presence of metabolic syndrome impact anxiety and depressive disorder screening results in middle aged and elderly individuals? A population based study. BMC Psychiatry 18(1) 5.

BACKGROUND: Depressive and anxiety disorders are common in primary care setting but often remain undiagnosed. Metabolic syndrome (MetS) is also

prevalent in the general population and can impair recognition of common mental disorders due to significant co-morbidity and overlap with psychiatric symptoms included in self-reported depression/anxiety screening tools. We investigated if MetS has an impact on the accuracy of current major depressive disorder (MDD) and generalized anxiety disorder (GAD) screening results using the Hospital Anxiety and Depression scale (HADS).METHODS: A total of 1115 (562 men; mean age 62.0+/-9.6 years) individuals of 45+ years of age were randomly selected from the general population and evaluated for current MetS; depressive and anxiety symptoms (HADS); and current MDD and GAD (Mini International Neuropsychiatric Interview [MINI]).RESULTS: The MetS was diagnosed in 34.4% of the study participants. Current MDD and GAD were more common in individuals with MetS relative to individuals without MetS (25.3% vs 14.2%, respectively, p<0.001; and 30.2% vs 20.9%, respectively, p<0.001). The ROC analyses demonstrated that optimal thresholds of the HADS-Depression subscale for current MDE were >=9 in individuals with MetS (sensitivity=87%, specificity=73% and PPV=52%) and >=8 in individuals without MetS (sensitivity=81%, specificity=78% and PPV=38%). At threshold of >=9 the HADS-Anxiety subscale demonstrated optimal psychometric properties for current GAD screening in individuals with MetS (sensitivity=91%, specificity=85% and PPV=72%) and without MetS (sensitivity=84%, specificity=83% and PPV=56%).CONCLUSIONS: The HADS is a reliable screening tool for current MDE and GAD in middle aged and elderly population with and without MetS. Optimal thresholds of the HADS-Depression subscale for current MDD is >=9 for individuals with MetS and >=8 - without MetS. Optimal threshold of the HADS-Anxiety subscale is >=9 for current GAD in individuals with and without MetS. The presence of MetS should be considered when interpreting depression screening results.

Cunningham, C., Riano, N. S. & Mangurian, C. 2018. Screening for metabolic syndrome in people with severe mental illness. Journal of Clinical Outcomes Management 25(1).

Objective: To review screening for metabolic syndrome in people with severe mental illness (SMI). Methods: Review of the literature. Results: Despite evidence-based metabolic screening guidelines, rates of metabolic screening remain low among people with SMI. Barriers to screening exist at the individual, organizational, and systems levels. Interventions to address these barriers range from point-of-care tools to systems-level reorganization towards population-based care. Conclusion: Greater systems-level interventions, particularly those that improve collaboration between mental health and primary care, are needed to improve metabolic monitoring and identify cardiovascular disease risk among people with SMI. Copyright © 2018 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.

Dikec, G., Arabaci, L. B., Uzunoglu, G. B., et al. 2018. Metabolic Side Effects in Patients Using Atypical Antipsychotic Medications During Hospitalization. Journal of Psychosocial Nursing & Mental Health Services 56(4) 28-37.

The current research evaluated metabolic side effects in inpatients (N = 271) using atypical antipsychotic medications in a psychiatric hospital in Turkey between June and December 2016. Data were collected via an information form created after reviewing the literature at the time of patients' hospitalization and discharge. According to the analysis, 73.8% of patients stated they experienced side effects from antipsychotic medications and 20.7% of patients experienced weight gain. A statistical difference was detected among body mass index, waist circumference, diastolic blood pressure, and heart rate during patient hospitalization and discharge. Patients using atypical anti-psychotic medications gained weight, had increased cardiovascular risk, and experienced adverse effects on their physical health during hospitalization. Mental health nurses should inform patients of medication effects and possible side effects, monitor side effects, and teach patients how to manage metabolic side effects. [Journal of Psychosocial Nursing and Mental Health Services, 56(4), 28-37.].

Ersoy, S. & Engin, V. S. 2018. Risk factors for polypharmacy in older adults in a primary care setting: A cross-sectional study. Clinical Interventions in Aging 13 2003-2011.

Purpose: Polypharmacy (PP) is a clinical challenge in older adults. Therefore, assessment of daily drug consumption (DDC) and its relationships is important. First-line health services have a crucial role in monitoring and preventing PP. In this study, we aimed to assess DDC and investigate the risk factors for higher DDC among older adults in a primary care setting. Patients and Methods: A total of 1,000 patients aged >=65 years who visited Melek Hatun Family Practice Center between December 1, 2014, and August 1, 2017, were enrolled in the study. All patients were seen either at the center or in their homes, and informed consent was obtained. Comprehensive geriatric assessment was performed for each subject. Data were analyzed using SPSS software (version 17). The daily number of medicines that each patient used (DDC) regardless of whether they were prescribed was the dependent variable. Relationships between DDC and other continuous variables were examined using Pearson's correlation. For between-group comparisons of DDC, Student's t-tests were performed. Result(s): Univariate tests showed relationships between DDC and various demographic and clinical parameters. The variables that remained significant at the last step of a stepwise linear regression analysis were metabolic syndrome, chronic pain, incontinence, increased serum creatinine level, increased Geriatric Depression Scale scores, reported gastric disturbances, and neutrophil/lymphocyte ratio. Conclusion(s): Along with certain chronic conditions, depressive symptoms and an inflammatory marker (neutrophil/lymphocyte ratio) were significantly and independently related to higher DDC. Longitudinal and larger studies are needed to further explore the multifaceted relationships of PP. Copyright © 2018 Ersoy and Engin.

Mattei, G., Padula, M. S., Rioli, G., et al. 2018. Metabolic Syndrome, Anxiety and Depression in a Sample of Italian Primary Care Patients. Journal of Nervous and Mental Disease 206(5) 316-324.

This cross-sectional study aimed at measuring the correlation and association of anxiety, depression and comorbid anxiety-depression symptoms with metabolic syndrome (MetS) in a sample of Italian primary care patients who attended their General Practitioner clinics over a 1-month period in 2013. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depressive symptoms. The sample was made up of 129 patients (57% women; mean age, 61 +/- 12 years). The prevalence of MetS varied from 40% (Adult Treatment Panel III-Revised criteria) to 48% (International Diabetes Federation criteria). The prevalence of symptoms of anxiety, depression and comorbid anxiety and depression was, respectively, 26%, 2%, and 15%. MetS (defined according to Adult Treatment Panel III-Revised criteria) was associated with comorbid anxiety-depressive symptoms (odds ratio [OR] = 3.84, 95% confidence interval [CI] = 1.26-11.71), but not with anxiety or depressive symptoms only. Out of the individual components of MetS, enlarged waist circumference was associated with anxiety symptoms (OR = 4.22, 95% CI = 1.56-11.44). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Meehan, T., Jones, D. & Stedman, T. 2018. Metabolic risk in patients participating in residential rehabilitation programs: how are we doing? Australasian Psychiatry.

Objectives: To examine the prevalence of metabolic syndrome and its association with clinical, demographic and lifestyle factors in patients with mental illness participating in residential rehabilitation. Method(s): A physical health audit of all consumers (n = 364) in publicly funded residential rehabilitation programs in Queensland was carried out in late 2016. Data collection focused on clinical, demographic and lifestyle factors associated with physical health. Result(s): Central obesity was identified in 80% of males and 89% of females and half of the patients (49.4%) met criteria for metabolic syndrome (MetS). The prevalence of MetS in Indigenous patients (66.1%) was 20% higher than the rate found in non-Indigenous patients (46.1%). Smoking, substance abuse, gender, Indigenous background, length of stay and rarely eating fruit and vegetables were individually associated with MetS. Conclusion(s): The prevalence of MetS in this cohort is almost double that of the general population, while the rate in Indigenous patients is among the highest reported for those with mental illness. Rehabilitation staff are encouraged to engage more fully in the monitoring of physical health status, sharing this information with consumers and primary care providers, and encouraging consumers to play a greater role in managing their physical health. Copyright © The Royal Australian and New Zealand College of Psychiatrists 2018.

Monge, M. C. & Loh, M. 2018. Medical complications of eating disorders in pediatric patients. Pediatric Annals 47(6) e238-e243.

Eating disorders affect millions of children, adolescents, and their families worldwide, and the pediatric primary care provider is often the first line of evaluation for these patients. Eating disorders affect nearly every system in the body, and signs and symptoms vary depending on patient behaviors (restrictive eating, binge eating, purging). Because the diagnosis is not always straightforward, a clinician's ability to recognize the potential medical complications of eating disorders early in their

course can help facilitate timely treatment and an appropriate level of support. Most of these medical complications improve or resolve with nutritional rehabilitation and cessation of eating disorder behaviors. Refeeding severely underweight patients should be approached with caution as there is potential for signifi-cant fluid and electrolyte derangement that may worsen a patient's clinical status. Prompt recognition of the medical complications of eating disorders can improve short-term and long-term health in these children and adolescents. Copyright © SLACK Incorporated.

Ortega, Y., Aragones, E., Pinol, J. L., et al. 2018. Impact of depression and/or anxiety on the presentation of cardiovascular events in a cohort with metabolic syndrome. StreX project: Five years of follow-up. Primary Care Diabetes 12(2) 163-171.

Objectives: To determine the role of anxiety and depression on the incidence of cardiovascular events (CVE) in a Catalonian population with metabolic syndrome (MetS) over a five-year follow-up according to the number/type of MetS criteria. Methods: Prospective study to determine the incidence of CVE according to the presence of anxiety and depression disorders among individuals with different combinations of clinical traits of the MetS. Setting: Primary Care, Catalonia (Spain). Subjects: 35-75 years old fulfilling MetS criteria without CVE at the initiation of follow-up (2009). We studied 16 MetS phenotypes [NCEP-ATPIII criteria] based on the presence of depression/anxiety. The primary endpoint was the incidence of CVE at five years. Results: We analyzed 401,743 people with MetS (17.2% of the population); 8.7% had depression, 16.0% anxiety and 3.8% both. 14.5% consumed antidepressants and 20.8% tranquilizers. At the 5-year follow-up, the incidence of CVE was 5.5%, being 6.4% in men and 4.4% in women. On comparing individuals with and without depression the incidence of CVE was 6.7% vs. 5.3%, respectively (p < 0.01), being 5.5% in both groups in relation to anxiety. Conclusion: Depression and anxiety play a role in the poor prognosis of patients with MetS. In Catalonia, the two predominant MetS phenotypes do not include obesity as a criterion. Copyright © 2017 Primary Care Diabetes Europe

Adams, D. & Sawhney, I. 2017. Deprescribing of psychotropic medication in a 30-year-old man with learning disability. European Journal of Hospital Pharmacy 24(1) 63-64.

A 30-year-old man with learning disability, living in a residential home with no documented mental health diagnosis, on the autistic spectrum was prescribed carbamazepine, olanzapine and propranolol to manage behaviour on a long-term basis. He was able to successfully discontinue both of his psychotropic medicines. The reduction was carried out in the community under the supervision of the learning disability psychiatrist. He is less tired, more alert and better able to express himself. He has expanded his activities and increased his access to the community. He is able to cope better with changes to his routine. His behaviours are well managed by the behavioural strategies in place and he has now been discharged by the psychiatrist to the general practitioner. Copyright © 2017 Published by the BMJ Publishing Group Limited.

Barnes, R. D. & Barber, J. A. 2017. Preliminary examination of metabolic syndrome response to motivational interviewing for weight loss as compared to an attentional control and usual care in primary care for individuals with and without binge-eating disorder. Eating Behaviors 26 108-113.

Motivational interviewing (MI) treatment for weight loss is being studied in primary care. The effect of such interventions on metabolic syndrome or binge eating disorder (BED), both highly related to excess weight, has not been examined in primary care. This study conducted secondary analyses from a randomized controlled trial to test the impact of MI for weight loss in primary care on metabolic syndrome. 74 adult participants with overweight/obesity recruited through primary care were randomized to 12 weeks of either MI, an attentional control, or usual care. Participants completed measurements for metabolic syndrome at pre- and post-treatment. There were no statistically significant differences in metabolic syndrome rates at pre-, X²(2) = 0.16, p = 0.921, or post-, X²(2) = 0.852, p = 0.653 treatment. The rates in metabolic syndrome, however, decreased for MI (10.2%) and attentional control (13.8%) participants, but not for usual care. At baseline, metabolic syndrome rates did not differ significantly between participants with BED or without BED across treatments. At post-treatment, participants with BED were significantly more likely to meet criteria for metabolic syndrome than participants without BED, X²(1) = 5.145, p = 0.023, phi = 0.273. Across treatments, metabolic syndrome remitted for almost a quarter of participants without BED (23.1%) but for 0% of those with BED. These preliminary results are based on a small sample and should be interpreted with caution, but they are the first to suggest that relatively low intensity MI weight loss interventions in primary care may decrease metabolic syndrome rates but not for individuals with BED. Copyright © 2017 Elsevier Ltd

Deruaz-Luyet, A., N'Goran, A. A., Senn, N., et al. 2017. Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: A cross-sectional study. BMJ Open 7 (6) (no pagination)(e013664).

Objective: To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. Methods: 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged >=18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. Results: The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (<=66 years old). Cluster analysis of chronic conditions with a prevalence >=5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. Conclusion: Given the emerging epidemic of multimorbidity in

industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices' patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients. Copyright © 2017 Article author(s).

Foresta, C., Ferlin, A., Lenzi, A., et al. 2017. The great opportunity of the andrological patient: cardiovascular and metabolic risk assessment and prevention. Andrology 5(3) 408-413.

Andrologists, cardiologists and diabetologists (and general practitioners) have the great opportunity to collaborate and find shared clinical workup for the benefit of a large number of men. Several evidence established a link between erectile dysfunction (ED), cardiovascular disease (CVD), diabetes, and metabolic syndrome. Not only these conditions share many risk factors and pathophysiological mechanisms but also an emerging paradigm indicates that ED is, in fact, an independent marker of cardiovascular disease risk, CV events and CV mortality. However, there is no consensus on the best cardiologic investigation in men with ED with no known CVD and, on the contrary, on what is the clinical and prognostic role of detecting ED during cardiovascular investigation and CVD risk assessment. Only vasculogenic ED, which represents the most common type of organic ED, indeed represents a harbinger of CVD, especially for younger patients, and might be diagnosed by dynamic penile color doppler ultrasonography, which represents a real cardiovascular imaging technique that give evidence on the presence of systemic endothelial dysfunction and atherosclerosis. Furthermore, assessment of glucose and lipid metabolism is warranted as first step workup in all ED patients, and diabetologists should ask their patients for erectile function, address ED patients to andrologists, and consider vasculogenic ED in the context of the cardiovascular and metabolic workup and in the context of diabetic complications. Sexual symptoms (and testosterone levels) should sound as harbinger for cardiovascular and metabolic investigation and cardiologists and diabetologists have the opportunity to have a symptom (erectile dysfunction) and a vascular test (penile color doppler) that help them in better management of patients, their comorbidities and complications.

Gopalraj, R. 2017. The Older Adult with Diabetes and The Busy Clinicians. Primary Care - Clinics in Office Practice 44(3) 469-479.

Busy primary care providers are in the frontline and see the bulk of older adults with diabetes. This vulnerable population is more prone to diabetic complications and hypoglycemia. In contrast to the younger patients with diabetes, lifestyle interventions are even more effective in older adults while the target A1c levels may need to be more relaxed for frail individuals. Geriatric syndromes can adversely affect diabetes care. A team with experts in different fields who understand the needs of older adults is essential for the adequate quality care of the whole individual with diabetes. Copyright © 2017 Elsevier Inc.

Kritharides, L., Chow, V. & Lambert, T. J. 2017. Cardiovascular disease in patients with schizophrenia. Medical Journal of Australia 206(2) 91-95.

Patients with schizophrenia die on average 25 years earlier than the general population, and this gap appears to be increasing. Most of the excess mortality is due to premature cardiovascular deaths rather than suicide. Many psychotropic agents are orexigenic and can increase weight and promote dyslipidaemia. Traditional cardiac risk factors are undertreated among patients with schizophrenia, and they are less likely to receive cardiac revascularisation than those without a mental illness. Clozapine is an atypical antipsychotic medication effective for treatment of refractory schizophrenia, but is associated with the risk of myocarditis and cardiomyopathy. Established protocols in Australia screen for myocarditis for patients who are initiating clozapine therapy and for long term monitoring for cardiomyopathy with echocardiography. Coordinated care between tertiary providers, general practitioners and primary health care professionals should monitor the physical health of people with psychosis or schizophrenia at least annually and treatment should be offered accordingly.

Marijnissen, R. M., Vogelzangs, N., Mulder, M. E., et al. 2017. Metabolic dysregulation and late-life depression: a prospective study. Psychological Medicine 47(6) 1041-1052.

BACKGROUND: Depression is associated with the metabolic syndrome (MS). We examined whether metabolic dysregulation predicted the 2-year course of clinical depression.METHOD: A total of 285 older persons (60 years) suffering from depressive disorder according to DSM-IV-TR criteria was followed up for 2 years. Severity of depression was assessed with the Inventory of Depressive Symptomatology (IDS) at 6-month intervals. Metabolic syndrome was defined according the National Cholesterol Education Programme (NCEP-ATP III). We applied logistic regression and linear mixed models adjusted for age, sex, years of education, smoking, alcohol use, physical activity, somatic co-morbidity, cognitive functioning and drug use (antidepressants, anti-inflammatory drugs) and severity of depression at baseline.RESULTS: MS predicted non-remission at 2 years (odds ratioper component = 1.26, 95% confidence interval 1.00-1.58), p = 0.047), which was driven by the waist circumference and HDL cholesterol. MS was not associated with IDS sum score. Subsequent analyses on its subscales, however, identified an association with the somatic symptom subscale score over time (interaction time x somatic subscale, p = 0.005), driven by higher waist circumference and elevated fasting glucose level.CONCLUSIONS: Metabolic dysregulation predicts a poor course of late-life depression. This finding supports the concept of 'metabolic depression', recently proposed on population-based findings of a protracted course of depressive symptoms in the presence of metabolic dysregulation. Our findings seem to be driven by abdominal obesity (as indicated by the waist circumference) and HDL cholesterol dysregulation.

Staveley, A., Soosay, I. & O'Brien, A. J. 2017. Metabolic monitoring in New Zealand district health board mental health services. New Zealand Medical Journal 130(1465) 44-52.

AIM: To audit New Zealand district health boards' (DHBs) metabolic monitoring policies in relation to consumers prescribed second-generation antipsychotic medications using a best practice guideline. METHODS: Metabolic monitoring policies from DHBs and one private clinic were analysed in relation to a best practice standard developed from the current literature and published guidelines relevant to metabolic syndrome. RESULTS: Fourteen of New Zealand's 20 DHBs currently have metabolic monitoring policies for consumers prescribed antipsychotic medication. Two of those policies are consistent with the literature-based guideline. Eight policies include actions to be taken when consumers meet criteria for metabolic syndrome. Four DHBs have systems for measuring their rates of metabolic monitoring. There is no consensus on who is clinically responsible for metabolic monitoring. CONCLUSIONS: Metabolic monitoring by mental health services in New Zealand reflects international experience that current levels of monitoring are low and policies are not always in place. Collaboration across the mental health and primary care sectors together with the adoption of a consensus guideline is needed to improve rates of monitoring and reduce current rates of physical health morbidities. Copyright © NZMA.

Thornton, L. M., Watson, H. J., Jangmo, A., et al. 2017. Binge-eating disorder in the Swedish national registers: Somatic comorbidity. International Journal of Eating Disorders 50(1) 58-65.

OBJECTIVE: To evaluate associations between binge-eating disorder (BED) and somatic illnesses and determine whether medical comorbidities are more common in individuals who present with BED and comorbid obesity.METHOD: Cases (n = 850) were individuals with a BED diagnosis in the Swedish eating disorders quality registers. Ten community controls were matched to each case on sex, and year, month, and county of birth. Associations of BED status with neurologic, immune, respiratory, gastrointestinal, skin, musculoskeletal, genitourinary, circulatory, and endocrine system diseases were evaluated using conditional logistic regression models. We further examined these associations by adjusting for lifetime psychiatric comorbidity. Amongst individuals with BED, we explored whether comorbid obesity was associated with risk of somatic disorders.RESULTS: BED was associated with most classes of diseases evaluated; strongest associations were with diabetes [odds ratio (95% confidence interval) = 5.7 (3.8; 8.7)] and circulatory systems [1.9 (1.3; 2.7)], likely indexing components of metabolic syndrome. Amongst individuals with BED, those with comorbid obesity were more likely to have a lifetime history of respiratory [1.5 (1.1; 2.1)] and gastrointestinal [2.6 (1.7; 4.1)] diseases than those without comorbid obesity. Increased risk of some somatic disease classes in individuals with BED was not simply due to obesity or other lifetime psychiatric comorbidity.DISCUSSION: The association of BED with many somatic illnesses highlights the morbidity experienced by individuals with BED. Clinicians treating patients with BED should be vigilant for medical comorbidities. Nonpsychiatric providers may be the first clinical contact for those with BED underscoring the importance of screening in primary care. © 2016 The Authors International Journal of Eating Disorders Published by Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:58-65).

Tso, G., Kumar, P., Jayasooriya, T., et al. 2017. Metabolic monitoring and management among clozapine users. Australasian Psychiatry 25(1) 48-52.

Objective: To assess, among clozapine users, the rates of monitoring, presence and treatment of metabolic syndrome and its components. Method(s): A chart review was conducted of all clozapine users who were followed up in community mental health clinics at two Metro South Health Hospitals over a 1-year period. Metabolic syndrome was diagnosed according to the International Diabetes Federation criteria. Result(s): We included 251 clozapine users. Only 43.4% (109/251) had data collected for all five metabolic syndrome parameters. Among these people, 45.0% (49/109) met criteria for metabolic syndrome, while 61.2% (30/49) of those with metabolic syndrome were offered appropriate treatments. Correspondence with primary care providers occurred in only 18.7% (n = 47). Non-pharmacological interventions, such as motivational interviewing and education about healthy lifestyle alternatives, occurred in 49.8% (n = 125). Conclusion(s): There is growing awareness of the importance of metabolic monitoring, however, there remain specific gaps in the collaborative work among mental health services, primary care providers and clozapine users, to ensure appropriate physical health interventions. Copyright © The Royal Australian and New Zealand College of Psychiatrists 2016.

Chun, T. H., Mace, S. E., Katz, E. R., et al. 2016. Executive summary: Evaluation and management of children with acute mental health or behavioral problems. Part II: Recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatrics 138 (3) (no pagination)(e20161574).

The number of children and adolescents seen in emergency departments (EDs) and primary care settings for mental health problems has skyrocketed in recent years, with up to 23% of patients in both settings having diagnosable mental health conditions. 1 -4 Even when a mental health problem is not the focus of an ED or primary care visit, mental health conditions, both known and occult, may challenge the treating clinician and complicate the patient's care.4 Although the American Academy of Pediatrics (AAP) has published a policy statement on mental health competencies and a Mental Health Toolkit for pediatric primary care providers, no such guidelines or resources exist for clinicians who care for pediatric mental health emergencies. 5, 6 Many ED and primary care physicians report paucity of training and lack of confidence in caring for pediatric psychiatry patients. The 2 clinical reports support the 2006 joint policy statement of the AAP and the American College of Emergency Physicians on pediatric mental health emergencies, 7 with the goal of addressing the knowledge gaps in this area. Although written primarily from the perspective of ED clinicians, it is intended for all clinicians who care for children and adolescents with acute mental health and behavioral problems. They are organized around the common clinical challenges pediatric caregivers face, both when a child or adolescent presents with a psychiatric chief complaint or emergency (part I) and when a mental health condition may be an unclear or complicating factor in a non-mental health ED presentation (part II). Part I of the clinical reports includes

discussions of Medical Clearance of Pediatric Psychiatric Patients, Suicide and Suicidal Ideation, Restraint of the Agitated Patient Including Verbal, Chemical, and Physical Restraint, and Coordination of Care With the Medical Home, and it can be accessed online at www.pediatrics.org/cgi/doi/10.1542/peds. 2016-1570. This executive summary is an overview of part II of the clinical reports. Full text of the following topics can be accessed online at www.pediatrics.org/cgi/doi/10.1542/peds. 2016-1573. © Copyright 2016 by the American Academy of Pediatrics.

Mattingly, G., Anderson, R. H., Mattingly, S. G., et al. 2016. The impact of cognitive challenges in major depression: the role of the primary care physician. Postgraduate Medicine 128(7) 665-671.

Nearly 1 in 5 Americans will struggle with major depression in their lives; some will have recurring bouts. Recent psychiatric research has given new attention to the prevalence of cognitive deficits in major depression and the impact such deficits have on remission and overall life functioning. When depression is partially treated i.e., leaving residual symptoms, patients have higher rates of relapse and lower functional outcomes. Impaired cognitive functioning is a frequent residual symptom, persisting in about 45% of patients even when emotional symptoms have improved, and results in a disproportionate share of the functional impairment, particularly in the workplace. Patients with depression have disrupted circuitry in brain regions responsible for cognition and it is therefore important to screen depressed patients for cognitive as well as emotional symptoms. Cognitive dysfunction should be evaluated in every mood disordered patient with validated self-report scales such as the Patient Health Questionnaire-9 or the Beck Depression Inventory and objective measures of cognitive function are also very very useful. Two easily administered tests are the Trails B Test and the Digit Symbol Substitution Test. Each take less than two minutes and measure working memory, executive function, and processing speed and can track cognitive improvement in depressed patients. Treatment of cognitive dysfunction in major depression is complicated by the 'serotonin conundrum': SSRI's frequently do not treat to full remission, and can cause cognitive blunting-actually adding to cognitive problems. Based on recent data including results from a recently completed meta-analysis by McIntyre and colleagues, an evidence-based algorithm for treating cognitive symptoms in depression is presented. A hierarchy of antidepressants and augmentation strategies based on the best available evidence is discussed. In conclusion, cognitive symptoms in major depressive disorder have been recognized as a target of therapeutic improvement by the FDA and have become a focus of clinical importance. Copyright © 2016 Informa UK Limited, trading as Taylor & Francis Group.

Nash, K., Ghinassi, F., Brar, J. S., et al. 2016. The development and implementation of an electronic health record tool for monitoring metabolic syndrome indices in patients with serious mental illness. Clinical Schizophrenia and Related Psychoses 10(3) 145-153.

Objectives: 1. A quality performance improvement (QI) project to implement an electronic screening and monitoring tool to record components of the metabolic

syndrome (e-MSD) during clinic visits by persons with serious mental illness (SMI). 2. To encourage psychiatrists to use this tool in their documentation. Methods: Working with the information technology staff, five psychiatrists developed, tested, revised and embedded the e-MSD tool into the medication management document within the electronic health record. A continuing medical education program on metabolic syndrome was developed and released to psychiatrists and mental health clinicians. Psychiatrist offices at one clinic were equipped with weighing scales, sphygmomanometers, waist circumference tapes, and a QI project was initiated. Results: At one month, 9 to 12% of the anthropometric measures (height, weight, body mass index, waist circumference, and blood pressure) were recorded in 974 unique patient encounters, and one year later the numbers moved upward from 15 to 41%. Toward the end of Year 1, a Patient Care Associate was hired to measure the anthropometric measures and, one year later, the documented rates increased to 75-80%. Laboratory recordings (glucose and lipids) remained <=8% throughout the first year, but moved upward to 25% in Year 2. Discussion: Notwithstanding significant administrative and technical support for this QI project, changing clinician practice to screen, monitor and document metabolic indices in persons with SMI in the ambulatory setting changed significantly after the hiring of a Patient Care Associate. Efforts to obtain laboratory measures in real time remain a challenge. Next steps include interventions to promote weight loss and smoking cessation in SMI patients, and effective communication with their primary care doctors.

Rothschild, S. K., Emery-Tiburcio, E. E., Mack, L. J., et al. 2016. BRIGHTEN Heart: Design and baseline characteristics of a randomized controlled trial for minority older adults with depression and cardiometabolic syndrome. Contemporary Clinical Trials 48 99-109.

Objectives: African American and Hispanic elderly are at elevated risk of both depression and cardiovascular disease, relative to non-Hispanic whites. Effective interventions are therefore needed to address depressive symptoms and to reduce these disparities. BRIGHTEN Heart was a behavioral randomized controlled trial to test the efficacy of a virtual team intervention in reducing depressive symptoms in minority elderly as measured by the 9-item Patient Health Questionnaire (PHQ9). Study design: 250 African American and Hispanic adults, age >=. 60 years, with comorbid depression and overweight/obesity were randomized. Participants randomized to the Intervention condition received a social work evaluation, team-based electronic consultation, case management, and psychotherapy over a 12 month period. Control participants were enrolled in a membership program that provided health classes and other services to support chronic disease self-management. Blinded research assistants completed assessments at baseline, and 6 and 12 months postrandomization. Results: The study population was characterized by low socioeconomic status, with 81.4% having a household income of less than $20,000. Although median depression scores were in the mild range, 25% of participants had scores showing moderate to severe depression at baseline. 75% of participants had four or more chronic conditions. Significant demographic and clinical differences were observed between the African American and Hispanic populations. Conclusions: BRIGHTEN Heart was designed to rigorously test the

efficacy of a multi-level intervention to reduce comorbid depressive symptoms and cardiovascular risk in minority elderly. Investigators successfully recruited a cohort well suited to testing the study hypothesis. Copyright © 2016 Published by Elsevier Inc.

Udo, T., White, M. A., Lydecker, J. L., et al. 2016. Biopsychosocial Correlates of Binge Eating Disorder in Caucasian and African American Women with Obesity in Primary Care Settings. European Eating Disorders Review 24(3) 181-186.

This study examined racial differences in eating-disorder psychopathology, eating/weight-related histories, and biopsychosocial correlates in women (n = 53 Caucasian and n = 56 African American) with comorbid binge eating disorder (BED) and obesity seeking treatment in primary care settings. Caucasians reported significantly earlier onset of binge eating, dieting, and overweight, and greater number of times dieting than African American. The rate of metabolic syndrome did not differ by race. Caucasians had significantly elevated triglycerides whereas African Americans showed poorer glycaemic control (higher glycated haemoglobin A1c [HbA1c]), and significantly higher diastolic blood pressure. There were no significant racial differences in features of eating disorders, depressive symptoms, or mental and physical health functioning. The clinical presentation of eating-disorder psychopathology and associated psychosocial functioning differed little by race among obese women with BED seeking treatment in primary care settings. Clinicians should assess for and institute appropriate interventions for comorbid BED and obesity in both African American and Caucasian patients. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.

Annamalai, A. & Tek, C. 2015. An overview of diabetes management in schizophrenia patients: Office based strategies for primary care practitioners and endocrinologists. International Journal of Endocrinology 2015 (no pagination)(969182).

Diabetes is common and seen in one in five patients with schizophrenia. It is more prevalent than in the general population and contributes to the increased morbidity and shortened lifespan seen in this population. However, screening and treatment for diabetes and other metabolic conditions remain poor for these patients. Multiple factors including genetic risk, neurobiologic mechanisms, psychotropic medications, and environmental factors contribute to the increased prevalence of diabetes. Primary care physicians should be aware of adverse effects of psychotropic medications that can cause or exacerbate diabetes and its complications. Management of diabetes requires physicians to tailor treatment recommendations to address special needs of this population. In addition to behavioral interventions, medications such as metformin have shown promise in attenuating weight loss and preventing hyperglycemia in those patients being treated with antipsychotic medications. Targeted diabetes prevention and treatment is critical in patients with schizophrenia and evidence-based interventions should be considered early in the course of treatment. This paper reviews the prevalence, etiology, and treatment of diabetes in schizophrenia and outlines office based

interventions for physicians treating this vulnerable population. Copyright © 2015 Aniyizhai Annamalai and Cenk Tek.

Barber, J. A., Schumann, K. P., Foran-Tuller, K. A., et al. 2015. Medication use and metabolic syndrome among overweight/obese patients with and without binge-eating disorder in a primary care sample. Primary Care Companion to the Journal of Clinical Psychiatry 17(5) 344.

Objective: To examine metabolic factors among overweight/obese individuals with binge-eating disorder (BED) and non-binge-eating overweight/obese (NBO) patients recruited from primary care and to examine and compare medication use by these groups. Method: Participants were 102 adults recruited for a weight loss study within primary care centers who were assessed for BED (28 [38%] met DSM-5 BED criteria). Participants completed a medication log, had physiologic measurements taken, and were evaluated for the presence of metabolic syndrome using 2 methods. Data were collected between February 2012 and October 2012. Results: The BED group had a higher mean body mass index (BMI), a higher pulse, and a larger waist circumference than the NBO group. Of the sample, 65% reported current medication use (prescription and/or over-the-counter medications): 19.6% took 3 to 4 medications and 15.7% took = 5 medications. Aside from vitamin and over-the-counter allergy pill use, there were no differences in medication use between BED and NBO patients. Full metabolic syndrome (= 3 criteria met) was present in 31.5% of the sample when using objective measurement alone, and 39.1% of the sample when defined by objective measurement and pharmacologic management. No significant differences were observed regardless of definition. Conclusions: Despite higher BMI, pulse, and waist circumference, the current sample of BED patients in primary care did not present with poorer metabolic health than NBO patients. Copyright © 2015 Physicians Postgraduate Press, Inc.

Barnes, R. D. & Ivezaj, V. 2015. A systematic review of motivational interviewing for weight loss among adults in primary care. Obesity Reviews 16(4) 304-318.

Motivational interviewing (MI) is a client-centred method of intervention focused on enhancing intrinsic motivation and behaviour change. A previous review of the literature and meta-analyses support the effectiveness of MI for weight loss. None of these studies, however, focused on the bourgeoning literature examining MI for weight loss among adults within primary care settings, which confers unique barriers to providing weight loss treatment. Further, the current review includes 19 studies not included in previous reviews or meta-analyses. We conducted a comprehensive review of PubMed, MI review papers, and citations from relevant papers. A total of 24 adult randomized controlled trials were identified. MI interventions typically were provided individually by a range of clinicians and compared with usual care. Few studies provided adequate information regarding MI treatment fidelity. Nine studies (37.5%) reported significant weight loss at post-treatment assessment for the MI condition compared with control groups. Thirteen studies (54.2%) reported MI patients achieving at least 5% loss of initial body weight. There is potential for MI to help primary care patients lose weight. Conclusions, however, must be drawn cautiously as more than half of the reviewed studies

showed no significant weight loss compared with usual care and few reported MI treatment fidelity. Copyright © 2015 World Obesity.

Butnoriene, J., Bunevicius, A., Saudargiene, A., et al. 2015. Metabolic syndrome, major depression, generalized anxiety disorder, and ten-year all-cause and cardiovascular mortality in middle aged and elderly patients. International Journal of Cardiology 190 360-6.

BACKGROUND: Studies investigating specifically whether metabolic syndrome (MetS) and common psychiatric disorders are independently associated with mortality are lacking. In a middle-aged general population, we investigated the association of the MetS, current major depressive episode (MDE), lifetime MDE, and generalized anxiety disorder (GAD) with ten-year all-cause and cardiovascular disease mortality.METHODS: From February 2003 until January 2004, 1115 individuals aged 45 years and older were randomly selected from a primary care practice and prospectively evaluated for: (1) MetS (The World Health Organization [WHO], National Cholesterol Education Program/Adult Treatment Panel III and International Diabetes Federation [IDF] definitions); (2) current MDE and GAD, and lifetime MDE (Mini International Neuropsychiatric Interview); and (3) conventional cardiovascular risk factors. Follow-up continued through January, 2013.RESULTS: During the 9.32 +/- 0.47 years of follow-up, there were 248 deaths, of which 148 deaths were attributed to cardiovascular causes. In women, WHO-MetS and IDF-MetS were associated with greater all-cause (HR-values range from 1.77 to 1.91; p-values <= 0.012) and cardiovascular (HR-values range from 1.83 to 2.77; p-values <= 0.013) mortality independent of cardiovascular risk factors and MDE/GAD. Current GAD predicted greater cardiovascular mortality (HR-values range from 1.86 to 1.99; p-values <= 0.025) independently from MetS and cardiovascular risk factors. In men, the MetS and MDE/GAD were not associated with mortality.CONCLUSIONS: In middle aged women, the MetS and GAD predicted greater 10-year cardiovascular mortality independently from each other; 10-year all-cause mortality was independently predicted by the MetS. MetS and GAD should be considered important and independent mortality risk factors in women.

Castillo, E. G., Rosati, J., Williams, C., et al. 2015. Metabolic Syndrome Screening and Assertive Community Treatment: A Quality Improvement Study. Journal of the American Psychiatric Nurses Association 21(4) 233-43.

Metabolic syndrome defines a collection of cardiometabolic illnesses that predict risk for poor physical health and early death and is highly prevalent among those with serious mental illness. Despite recommendations for routine monitoring, those with serious mental illness frequently do not receive physical health screenings. We conducted a quality improvement (QI) project to increase rates of metabolic syndrome screening in three New York City Assertive Community Treatment (ACT) teams. The project, conducted from December 2010 to May 2011, involved educational sessions for staff and consumers and a systematic screening protocol. We collected complete metabolic syndrome screening measurements for 71% of participating ACT consumers. We found metabolic risk to be nearly universal

among participants, with over half diagnosed with metabolic syndrome. We also found high rates of previously undiagnosed hypertension, diabetes, and dyslipidemia. We describe the resources and obstacles we encountered in our QI project to make systematic metabolic screening a routine part of ACT care. This QI project suggests that ACT teams can take a leadership role in screening their consumers for physical health issues, aligning with recent policy trends to better integrate behavioral health and primary care services.

Eskelinen, S., Sailas, E., Joutsenniemi, K., et al. 2015. Clozapine use and sedentary lifestyle as determinants of metabolic syndrome in outpatients with schizophrenia. Nordic Journal of Psychiatry 69(5) 339-45.

BACKGROUND: Schizophrenia patients are in danger of developing metabolic syndrome (MetS) and its outcomes type 2 diabetes and cardiovascular disease. Antipsychotic treatment and adverse lifestyle increase the burden of metabolic problems in schizophrenia, but little is known about the role of patients' current psychiatric problems and living arrangements in MetS.AIMS: This study aims to evaluate correlations between MetS, severity of psychiatric symptoms, living arrangements, health behaviour and antipsychotic medication in outpatients with schizophrenia spectrum disorders.METHODS: A general practitioner and psychiatric nurses performed a comprehensive health examination for all consenting patients with schizophrenia spectrum disorders treated in a psychosis outpatient clinic. Examination comprised of an interview, a questionnaire, measurements, laboratory tests and a general clinical examination. Diagnosis of MetS was made according to International Diabetes Federation (IDF) definition. Correlations were calculated and logistic regression analysis performed with SAS.RESULTS: 276 patients (men n = 152, mean age +/- standard deviation = 44.9 +/- 12.6 years) participated in the study; 58.7% (n = 162) of them had MetS according to the IDF definition. Clozapine use doubled the risk of MetS (OR = 2.04, 95% CI 1.09-3.82, P = 0.03), whereas self-reported regular physical activity decreased the risk significantly (OR = 0.32, 95% CI 0.18-0.57, P < 0.001). We found no correlations between MetS and living arrangements or current severity of psychiatric symptoms.CONCLUSIONS: MetS was alarmingly common in our sample. Even moderate physical activity was associated with decreased risk of MetS. Promotion of a physically active lifestyle should be one of the targets in treatment of schizophrenia, especially in patients using clozapine.

Innes, K. E., Kandati, S., Flack, K. L., et al. 2015. The association of restless legs syndrome to history of gestational diabetes in an appalachian primary care population. Journal of Clinical Sleep Medicine 11(10) 1121-1130.

Objective: Restless legs syndrome (RLS) is a burdensome sensorimotor disorder that has been linked to diabetes and obesity. However, the relationship of RLS to gestational diabetes mellitus (GDM), a common pregnancy complication strongly associated with obesity and a harbinger of diabetes, remains unknown. In this study, we examined the association of RLS to history of GDM in a sample of older female primary care patients. Methods: Participants were community-dwelling

women aged >= 40 years drawn from an anonymous survey study of West Virginia adult primary care patients. Data gathered included detailed information on demographics, lifestyle factors, reproductive history, sleep patterns, and medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or had missing data on key variables were excluded from the analyses. Results: Of the 498 participants included in the fi nal analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms at least once/week). After adjustment for demographics, lifestyle characteristics, body mass index, diabetes and other comorbid conditions, parity, and other factors, those reporting history of GDM were almost three times as likely to meet criteria for RLS (odds ratio [OR] = 2.7, 95% confi dence interval [CI] = 1.3, 5.3). This association increased in magnitude with increasing symptom frequency (adjusted OR for RLS symptoms >= 3x/week = 4.8, CI 2.1, 11.2, p for trend = 0.004). Conclusions: History of GDM was strongly and positively related to RLS in this study of older female primary care patients, offering further support for a possible role of metabolic dysregulation in RLS development.

Jang, J., Futeran, S., Large, M., et al. 2015. An audit of general practitioner involvement in public community mental health care. Australasian Psychiatry 23(5) 571-4.

OBJECTIVE: Existing guidelines suggest that collaboration between general practitioners and mental health services may improve the physical health of people with serious mental illness. This study investigated the extent of general practitioner involvement in a community mental health centre and examined whether the presence of a documented general practitioner in the patient's medical records was associated with markers of better health outcomes.METHODS: The medical records of current patients were audited, including those receiving medical care and case management and those only receiving medical care. The demographic and diagnostic information, evidence of metabolic screening, blood test results, and medications of patients with a recorded general practitioner were compared with those of patients with no recorded general practitioner.RESULTS: Ninety-eight of 191 (51%) of patients had details of a general practitioner documented in their medical records. There were no significant differences in rates of metabolic screening between the two groups. Those with a general practitioner had more medical diagnoses and were taking a greater number of psychiatric medications.CONCLUSION: Although the medical comorbidities of serious mental illness are becoming increasingly recognised, our findings suggest the need for ongoing and coordinated efforts by policymakers, general practitioners, mental health services and patients to ensure the health and longevity of people with serious mental illness.

Lai, C. L., Chan, H. Y., Pan, Y. J., et al. 2015. The Effectiveness of a Computer Reminder System for Laboratory Monitoring of Metabolic Syndrome in Schizophrenic Outpatients Using Second-generation Antipsychotics. Pharmacopsychiatry 48(1) 25-29.

Introduction: A computer reminder system (CRS) may help psychiatrists follow guidelines and monitor patients at risk of metabolic syndrome. This study explores the effectiveness of a CRS for outpatients with schizophrenia. Methods: The study data were collected from July 2004 to July 2008. A CRS was implemented in July 2006. The intervention group was patients taking either clozapine, olanzapine, risperidone, or quetiapine with a CRS. The control group was patients taking either sulpiride or zotepine without a CRS. We defined a qualified patient visit (QPV) as a visit in which metabolic monitoring adhered to established guidelines when the patient visit was within 6 months of performing the recommended laboratory examinations. We compared the percentage difference in QPVs between the 2 study groups. Results: The percentage of QPVs in the intervention group was significantly higher than the control group (OR=3.51, 95% CI=1.83~6.73, P=0.0002) after adjusting potential confounding factors. The intervention group was divided into a high metabolic risk (clozapine and olanzapine) subgroup and an intermediate metabolic risk (risperidone and quetiapine) subgroup and compared with the control group. The percentage of QPVs in the high risk subgroup was significantly higher than the intermediate risk subgroup (OR=4.27, 95% CI=2.71~6.75, p<0.0001) and control group (OR=6.99, 95% CI=3.48~14.07, p<0.0001). Discussion: The percentage of QPVs in the intervention group was higher than the control group and the different metabolic risk of SGAs also influenced the performance of laboratory examinations. Further studies are needed to confirm the results of our studies. Copyright © Georg Thieme Verlag KG Stuttgart.

Butnoriene, J., Bunevicius, A., Norkus, A., et al. 2014. Depression but not anxiety is associated with metabolic syndrome in primary care based community sample. Psychoneuroendocrinology 40 269-76.

INTRODUCTION: Metabolic syndrome (MetS) and depression are considered important risk factors for diabetes and cardiovascular disease. Recent evidence suggests that depression can be an important predictor of MetS. Data on the association between anxiety and MetS remain mixed. In a large primary care based community sample we investigated an association of depressive and anxiety disorders and symptoms with MetS.METHODS: A total of 1115 (51% men, mean age 62.0 +/- 9.6 years) randomly selected individuals of 45 years and older were evaluated for: (i) MetS using the World Health Organization (WHO), National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III) and International Diabetes Federation (IDF) criteria; (ii) current major depressive episode (MDE) and current generalized anxiety disorder (GAD), the Mini International Neuropsychiatric interview; (iii) lifetime MDE; and (iv) symptoms of depression and anxiety, the Hospital Anxiety and Depression scale (HADS). Socio-demographic characteristics (education, residence, marital status and social status) and medical histories (physical activity, smoking status, alcohol consumption and histories of myocardial infarction and stroke) were also evaluated.RESULTS: After adjusting for socio-demographic status, medical histories and current GAD, current MDE and lifetime MDE were associated with greater prevalence of MetS according to the WHO criteria (OR=1.7, 95%CI [1.1-2.7] and

OR=3.7, 95%CI [2.4-5.7], respectively, p <= 0.001). Lifetime MDE was also associated with MetS according to the IDF and NCEP/ATP III criteria. On the other hand, current GAD was not associated with MetS in multivariate regression models when adjusted for current MDE. Similar results were obtained when evaluating an association between depression/anxiety symptoms and MetS, since elevated depressive, but not anxiety, symptoms were independently associated with MetS.CONCLUSIONS: Depressive, but not anxiety, disorders and symptoms are associated with greater prevalence rate of MetS. Assessment and management of MetS risk factors should be considered in depressed individuals.

Bystritsky, A., Danial, J. & Kronemyer, D. 2014. Interactions between diabetes and anxiety and depression: Implications for treatment. Endocrinology and Metabolism Clinics of North America 43(1) 269-283.

Anxiety or depression may be a risk factor for the development of diabetes. This relationship may occur through a combination of genetic predispositions; epigenetic contingencies; exacerbating conditions such as metabolic syndrome (a precursor to diabetes); and other serious medical conditions. Medications used to treat anxiety and depression have significant side effects, such as weight gain, further increasing the possibility of developing diabetes. These components combine, interact, and reassemble to create a precarious system for persons with, or predisposed to, diabetes. Clinicians must be aware of these interrelationships to adequately treat the disease. © 2014 Elsevier Inc.

Godin, O., Etain, B., Henry, C., et al. 2014. Metabolic syndrome in a French cohort of patients with bipolar disorder: results from the FACE-BD cohort. Journal of Clinical Psychiatry 75(10) 1078-85; quiz 1085.

OBJECTIVE: The aim of this study was to estimate the prevalence of metabolic syndrome (MetS) and its components in a cohort of French patients with bipolar disorder; determine correlations with sociodemographic, clinical, and treatment-related factors; and investigate the gap between optimal care and effective care of the treated patients.METHOD: 654 bipolar disorder patients from the FACE-BD cohort were included from 2009 to 2012. Sociodemographic and clinical characteristics, lifestyle information, and data on antipsychotic treatment and comorbidities were collected, and a blood sample was drawn. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to confirm the diagnosis of bipolar disorder. Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria.RESULTS: 18.5% of individuals with bipolar disorder met criteria for MetS. Two-thirds of bipolar disorder patients did not receive adequate treatment for MetS components. Multivariate analysis showed that risk of MetS in men was nearly twice that in women (OR = 1.9; 95% CI, 1.0-3.8), and older patients had a 3.5 times higher risk (95% CI, 1.5-7.8) of developing MetS than patients under the age of 35 years. Moreover, patients receiving antipsychotic treatment had a 2.3 times increased risk (95% CI, 1.2-3.5) of having MetS, independent of other potential confounders.

CONCLUSIONS: The prevalence of MetS is high in bipolar disorder patients, and there was considerable undertreatment of the components of MetS in this population. The prevention and treatment of cardiovascular diseases in these patients should be assessed systematically. The findings highlight the need for integrated care, with more interaction and coordination between psychiatrists and primary care providers.

Kemp, D. E., Sylvia, L. G., Calabrese, J. R., et al. 2014. General medical burden in bipolar disorder: Findings from the LiTMUS comparative effectiveness trial. Acta Psychiatrica Scandinavica 129(1) 24-34.

Objective: This study examined general medical illnesses and their association with clinical features of bipolar disorder. Method: Data were cross-sectional and derived from the Lithium Treatment - Moderate Dose Use Study (LiTMUS), which randomized symptomatic adults (n = 264 with available medical comorbidity scores) with bipolar disorder to moderate doses of lithium plus optimized treatment (OPT) or to OPT alone. Clinically significant high and low medical comorbidity burden were defined as a Cumulative Illness Rating Scale (CIRS) score >=4 and <4 respectively. Results: The baseline prevalence of significant medical comorbidity was 53% (n = 139). Patients with high medical burden were more likely to present in a major depressive episode (P = .04), meet criteria for obsessive-compulsive disorder (P = .02), and experience a greater number of lifetime mood episodes (P = 0.02). They were also more likely to be prescribed a greater number of psychotropic medications (P = .002). Sixty-nine per cent of the sample was overweight or obese as defined by body mass index (BMI), with African Americans representing the racial group with the highest proportion of stage II obesity (BMI >=35; 31%, n = 14). Conclusion: The burden of comorbid medical illnesses was high in this generalizable sample of treatment-seeking patients and appears associated with worsened course of illness and psychotropic medication patterns. © 2013 John Wiley & Sons A/S.

Kolbaek, P., Schioth, E., Aagaard, J., et al. 2014. Follow-up interventions in persons with schizophrenia and metabolic syndrome. Australian & New Zealand Journal of Psychiatry 48(11) 1059-60.

Luppino, F. S., Bouvy, P. F., Giltay, E. J., et al. 2014. The metabolic syndrome and related characteristics in major depression: Inpatients and outpatients compared metabolic differences across treatment settings. General Hospital Psychiatry 36(5) 509-515.

Objective: We aimed to systematically compare patients with major depressive disorder from three different treatment settings (a primary care outpatient, a secondary care outpatient and one inpatient sample), with regard to metabolic syndrome (MetSyn) prevalences, individual MetSyn components and related metabolic variables. Method: The outpatient samples were drawn from the ongoing Netherlands Study of Depression and Anxiety (302 primary care and 445 secondary care outpatients). The inpatient sample (n=80) was recruited from five

Dutch mental health hospitals. The assessments of MetSyn and related variables [waist circumference (WC), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, glucose, systolic and diastolic blood pressure (SBP, DBP), body mass index (BMI), waist-hip ratio (WHR), LDL and total cholesterol (TC)] were compared using analysis of (co)variance and regression analysis, whereas medication analyses examined the extent to which clinical differences (e.g., depression severity or medication use) mediated the observed metabolic differences across setting. Results: MetSyn prevalences (26% primary, 24% secondary care and 28% inpatients) did not significantly differ (P=.71). WC, BMI, LDL cholesterol, glucose and DBP were not significantly different across settings. However, WHR, TC and triglyceride levels were higher in inpatients than in both outpatients groups, while HDL cholesterol levels and SBP were lower. There was some mediating role for tricyclic and non-selective serotonin-reuptake inhibitor antidepressant use, but overall, the mediating role of clinical differences was limited. Conclusions: Although overall MetSyn prevalences did not differ, patterns of individual MetSyn-related variables differed more markedly across depressed inpatients and outpatients. Inpatients showed more adverse WHR and serum lipid profiles, while SBP levels were lower. © 2014 Elsevier Inc.

Morgan, V. A., McGrath, J. J., Jablensky, A., et al. 2014. Psychosis prevalence and physical, metabolic and cognitive co-morbidity: data from the second Australian national survey of psychosis. Psychological Medicine 44(10) 2163-76.

BACKGROUND: There are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities.METHOD: The 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18-64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants.RESULTS: The 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18-64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence.CONCLUSIONS: Our findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.

Nicolaidis, C., Kripke, C. C. & Raymaker, D. 2014. Primary care for adults on the autism spectrum. Medical Clinics of North America 98(5) 1169-91.

Autism spectrum disorder (ASD) is defined by differences in social communication and restricted, repetitive patterns of behavior, interests, or activities. Skills and challenges can change depending on environmental stimuli, supports, and stressors. Quality of life can be improved by the use of accommodations, assistive technologies, therapies to improve adaptive function or communication, caregiver training, acceptance, access, and inclusion. This article focuses on the identification of ASD in adults, referrals for services, the recognition of associated conditions, strategies and accommodations to facilitate effective primary care services, and ethical issues related to caring for autistic adults.

Trief, P. M., Cibula, D., Delahanty, L. M., et al. 2014. Depression, stress, and weight loss in individuals with metabolic syndrome in SHINE, a DPP translation study. Obesity 22(12) 2532-2538.

Objective To examine the relationships between elevated depression symptoms (EDS) or stress and weight loss in SHINE, a telephonic, primary-care based, translation of the Diabetes Prevention Program. Methods N-=-257 adults with metabolic syndrome were randomized to individual (IC) or group (CC) phone participation. Weight, depression, anti-depressant use (ADMs), and stress (baseline, 6 months, 1 and 2 years) were assessed. Univariate analyses used linear and logistic regression, t tests for continuous variables and exact tests for categorical variables. Stratified analyses assessed modifiers of effects of depression/stress on weight loss. Results Approximately 35% reported EDS, with no change over time. Approximately 28% of all participants used ADMs. Participants with EDS had lower mean % weight loss and a smaller % who achieved >=5% weight loss. Participants with EDS were less likely to be "completers" (40.1% vs. 61.5%, P-=-0.002), coached (48.0% vs. 60.7%, P-=-0.049), or log diet/activity (19.4% vs. 42.7%, P-<-0.001), behaviors related to weight loss. Results were similar for high stress. ADM use had no independent effect on weight loss. Conclusions Individuals with metabolic syndrome and EDS and/or high stress were less likely to lose significant weight. Pre-intervention depression and stress screening to intervene may improve weight loss. Copyright © 2014 The Obesity Society.

Babic, R., Maslov, B., Babic, D., et al. 2013. The prevalence of metabolic syndrome in patient with posttraumatic stress disorder. Psychiatria Danubina 25 Suppl 1 45-50.

BACKGROUND: Although the connection between body and soul is written in the Bible, research papers haven't given much attention to it until the past few decades. Recently, both here and abroad, there have been more studies that investigate the prevalence of various somatic disorders in psychiatric patients, including metabolic syndrome.OBJECTIVE: The objective of this study was to establish the prevalence of metabolic syndrome and it's components in patients with posttraumatic stress disorder (PTSD).

SUBJECTS AND METHODS: Metabolic syndrome and its components were investigated in 60 patients with chronic PTSD conditioned by the war and in 60 patients treated for somatic problems by their family physician in Mostar.RESULTS: The prevalence of metabolic syndrome was statistically significantly higher in patients with PTSD (48.3%) than in the control group (25%) (P=0.008) and the number of its individual components (test group 2.38+/-1.30 compared to control group 1.72+/-1.24) (P=0.005). PTSD patients diagnosed with metabolic syndrome had significantly more frequent hyperglycemia (P=0.010) and abdominal obesity (P=0.044) compared to the control group.CONCLUSION: The prevalence of metabolic syndrome increased in patients with PTSD compared to the control group.

Bergqvist, A., Karlsson, M., Foldemo, A., et al. 2013. Preventing the development of metabolic syndrome in people with psychotic disorders-difficult, but possible: Experiences of staff working in psychosis outpatient care in Sweden. Issues in Mental Health Nursing 34(5) 350-358.

The aim of this study was to explore mental health staffs' experiences of assisting people with psychotic disorders to implement lifestyle changes in an effort to prevent metabolic syndrome. Qualitative interviews were conducted with 12 health care professionals working in psychosis outpatient care in Sweden. Data were analysed using a qualitative content analysis. The results illustrate that implementation of lifestyle changes among people with psychotic disorders was experienced as difficult, but possible. The greatest obstacles experienced in this work were difficulties due to the reduction of cognitive functions associated with the disease. Guidelines available to staff in order to help them identify and prevent physical health problems in the group were not always followed and the content was not always relevant. Staff further described feelings of uncertainty about having to motivate people to take anti-psychotic medication while simultaneously being aware of the risks of metabolic deviations. Nursing interventions focusing on organising daily routines before conducting a more active prevention of metabolic syndrome, including information and practical support, were experienced as necessary. The importance of healthy eating and physical activity needs to be communicated in such a way that it is adjusted to the person's cognitive ability, and should be repeated over time, both verbally and in writing. Such efforts, in combination with empathic and seriously committed community-based social support, were experienced as having the best effect over time. Permanent lifestyle changes were experienced as having to be carried out on the patient's terms and in his or her home environment. © 2013 Informa Healthcare USA, Inc.

Garvey, C. 2013. Identification and treatment of patients with early COPD. Current Respiratory Medicine Reviews 9(6) 407-417.

This review addresses the need for greater awareness, timely and accurate diagnoses, as well as effective management of mild-to-moderate COPD in the primary care setting. A PubMed literature search was used to identify the epidemiology of undiagnosed COPD, and the potential benefits of early diagnosis that may result in improved outcomes for these patients. Lung function impairment

and disabling symptoms have been detected in patients with mild undiagnosed COPD, with these patients showing significant limitations and physical impairment, which worsen over time. The 2014 GOLD guidelines emphasize the need for early detection, prevention, and approaches to management of COPD, including smoking cessation, early pharmacotherapy, and pulmonary rehabilitation, and recommend using a fixed forced expiratory volume in 1 second/forced vital capacity (FEV<inf>1</inf>/FVC) ratio of <0.70 in addition to symptoms and exacerbation risk to confirm diagnosis. Screening may represent a feasible approach to identify patients with mild-to-moderate disease. Screening tools, i.e. questionnaires and targeted spirometry, can aid early detection of COPD in people identified as at risk. Pharmacologic and non-pharmacologic interventions have been shown to improve patient care and quality of life; however, to date, only smoking cessation has been shown conclusively to slow COPD disease progression. Primary care professionals are in an excellent position to identify and diagnose COPD, and implement recommended treatment programmes, before it becomes advanced. © 2013 Bentham Science Publishers.

Heller, M. M., Wong, J. W., Lee, E. S., et al. 2013. Delusional infestations: Clinical presentation, diagnosis and treatment. International Journal of Dermatology 52(7) 775-783.

Patients with delusional infestations (DI), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non-living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self-destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described. © 2013 The International Society of Dermatology.

Kahl, K. G., Greggersen, W., Schweiger, U., et al. 2013. Prevalence of the metabolic syndrome in patients with borderline personality disorder: results from a cross-sectional study. European Archives of Psychiatry & Clinical Neuroscience 263(3) 205-13.

Metabolic syndrome (MetS) is an important risk factor for the development of type-2 diabetes and coronary artery disease. We aimed to compare the MetS prevalence in patients with borderline personality disorder (BPD) with comparison subjects followed in primary care from a similar region. One hundred and thirty-five BPD patients according to DSM-IV diagnostic criteria were compared to 1009 subjects from primary care. We used the American Heart Association/National Heart, Lung and Blood Institute criteria to determine the rate of MetS. The age-standardized prevalence of MetS was more than double in patients with BPD compared to comparison subjects (23.3 vs. 10.6 %, p < 0.05). Regarding individual MetS criteria, hyperglycemia was significantly more prevalent in both genders (p < 0.05). Abdominal obesity (p < 0.05) and hypertriglyceridemia (p < 0.05) were significantly

higher only in women with BPD. Within BPD patients, an increased rate of MetS was associated with higher BMI (p = 0.004), age (p = 0.03), treatment with second-generation antipsychotics (quetiapine, olanzapine and clozapine; p = 0.032), dysthymia (p = 0.031), panic disorder (p = 0.032), benzodiazepine dependency (p = 0.015) and binge eating disorder p = 0.02). Our results demonstrate an increased MetS rate, dysregulated glucose and lipid metabolism in patients with BPD. Cardiometabolic monitoring and careful screening for physical health conditions among people with BPD is warranted.

Licht, C. M. M., De Geus, E. J. C. & Penninx, B. W. J. H. 2013. Dysregulation of the autonomic nervous system predicts the development of the metabolic syndrome. Journal of Clinical Endocrinology and Metabolism 98(6) 2484-2493.

Context: Stress is suggested to lead to metabolic dysregulations as clustered in the metabolic syndrome. Although dysregulation of the autonomic nervous system is found to associate with the metabolic syndrome and its dysregulations, no longitudinal study has been performed to date to examine the predictive value of this stress system in the development of the metabolic syndrome. Objective: We examined whether autonomic nervous system functioning predicts 2-year development of metabolic abnormalities that constitute the metabolic syndrome. Design: Data of the baseline and 2-year follow-up assessment of a prospective cohort: the Netherlands Study of Depression and Anxiety was used. Setting: Participants were recruited in the general community, primary care, and specialized mental health care organizations. Participants: A group of 1933 participants aged 18-65 years. Main outcome measures: The autonomic nervous system measures included heart rate (HR), respiratory sinus arrhythmia (RSA; high RSA reflecting high parasympathetic activity), pre-ejection period (PEP; high PEP reflecting low sympathetic activity), cardiac autonomic balance (CAB), and cardiac autonomic regulation (CAR). Metabolic syndrome was based on the updated Adult Treatment Panel III criteria and included high waist circumference, serum triglycerides, blood pressure, serum glucose, and low high-density lipoprotein (HDL) cholesterol. Results: Baseline short PEP, low CAB, high HR, and CAR were predictors of an increase in the number of components of the metabolic syndrome during follow-up. High HR and low CAB were predictors of a 2-year decrease in HDL cholesterol, and 2-year increase in diastolic and systolic blood pressure. Short PEP and high CAR also predicted a 2-year increase in systolic blood pressure, and short PEP additionally predicted 2-year increase in diastolic blood pressure. Finally, a low baseline RSA was predictive for subsequent decreases in HDL cholesterol. Conclusion: Increased sympathetic activity predicts an increase in metabolic abnormalities over time. These findings suggest that a dysregulation of the autonomic nervous system is an important predictor of cardiovascular diseases and diabetes through dysregulating lipid metabolism and blood pressure over time. Copyright © 2013 by The Endocrine Society.

Nover, C. & Jackson, S. S. 2013. Primary care-based educational interventions to decrease risk factors for metabolic syndrome for adults with major

psychotic and/or affective disorders: a systematic review. Systematic Reviews 2 116.

BACKGROUND: Individuals with major psychotic and/or affective disorders are at increased risk for developing metabolic syndrome due to lifestyle- and treatment-related factors. Numerous pharmacological and non-pharmacological interventions have been tested in inpatient and outpatient mental health settings to decrease these risk factors. This review focuses on primary care-based non-pharmacological (educational or behavioral) interventions to decrease metabolic syndrome risk factors in adults with major psychotic and/or affective disorders.METHODS: The authors conducted database searches of PsychINFO, MEDLINE and the Cochrane Database of Systematic Reviews, as well as manual searches and gray literature searches to identify included studies.RESULTS: The authors were unable to identify any studies meeting a priori inclusion criteria because there were no primary care-based studies.CONCLUSIONS: This review was unable to demonstrate effectiveness of educational interventions in primary care. Interventions to decrease metabolic syndrome risk have been demonstrated to be effective in mental health and other outpatient settings. The prevalence of mental illness in primary care settings warrants similar interventions to improve health outcomes for this population.

Poli, A., Marangoni, F., Avogaro, A., et al. 2013. Moderate alcohol use and health: a consensus document. Nutrition Metabolism & Cardiovascular Diseases 23(6) 487-504.

AIMS: The aim of this consensus paper is to review the available evidence on the association between moderate alcohol use, health and disease and to provide a working document to the scientific and health professional communities.DATA SYNTHESIS: In healthy adults and in the elderly, spontaneous consumption of alcoholic beverages within 30 g ethanol/d for men and 15 g/d for women is to be considered acceptable and do not deserve intervention by the primary care physician or the health professional in charge. Patients with increased risk for specific diseases, for example, women with familiar history of breast cancer, or subjects with familiar history of early cardiovascular disease, or cardiovascular patients should discuss with their physician their drinking habits. No abstainer should be advised to drink for health reasons. Alcohol use must be discouraged in specific physiological or personal situations or in selected age classes (children and adolescents, pregnant and lactating women and recovering alcoholics). Moreover, the possible interactions between alcohol and acute or chronic drug use must be discussed with the primary care physician.CONCLUSIONS: The choice to consume alcohol should be based on individual considerations, taking into account the influence on health and diet, the risk of alcoholism and abuse, the effect on behaviour and other factors that may vary with age and lifestyle. Moderation in drinking and development of an associated lifestyle culture should be fostered.

Ratliff, J. C., Palmese, L. B., Reutenauer, E. L., et al. 2013. Obese schizophrenia spectrum patients have significantly higher 10-year general cardiovascular

risk and vascular ages than obese individuals without severe mental illness. Psychosomatics 54(1) 67-73.

BACKGROUND: Individuals with schizophrenia have a life expectancy that is 20 years less than the general population, along with high rates of obesity and cardiovascular disease (CVD) mortality.OBJECTIVE: This study assessed the 10-year general CVD risk and vascular ages of 106 obese schizophrenia spectrum patients and 197 demographically matched obese controls without severe mental illness (SMI) from the National Health and Nutrition Examination Survey (NHANES).METHODS: Vascular age and general CVD risk were calculated using the Framingham global CVD calculator, which incorporates age, sex, total and HDL cholesterol levels, systolic blood pressure, smoking status, and diabetes or hypertension treatment.RESULTS: Obese schizophrenia spectrum patients had a mean vascular age that was 14.1 years older than their mean actual age, whereas obese NHANES participants had only a 6.7-year difference. The probability of experiencing a CVD event within the next 10 years was 10.7% for obese patients and 8.5% for obese NHANES participants.CONCLUSION: These findings suggest that schizophrenia spectrum patients experience increased metabolic risk independent of weight. Primary care clinicians can utilize general CVD risk and vascular age scores to communicate metabolic risk more easily and to help make treatment decisions.

Shackelford, J. R., Serna, M., Mangurian, C., et al. 2013. Descriptive analysis of a novel health care approach: Reverse collocation-primary care in a community mental health "home". Primary Care Companion to the Journal of Clinical Psychiatry 15(5).

Objective: Persons with serious mental illness have increased rates of chronic medical conditions, have limited access to primary care, and incur significant health care expenditures. Few studies have explored providing medical care for these patients in the ambulatory mental health setting. This study describes a real-world population of mental health patients receiving primary care services in a community mental health clinic to better understand how limited primary care resources are being utilized. Method: Chart review was performed on patients receiving colocated primary care (colocation group, N = 143) and randomly chosen patients receiving mental health care only (mental-health group, N = 156) from January 2006 through June 2011. Demographic and mental and physical health variables were assessed. Results: Compared to the mental-health group, the colocation patients had more psychiatric hospitalizations (mean = 1.07 vs 0.23, P <.01), were more likely to be homeless (P <.01), and were more likely to require intensive case management (P <.01). Interestingly, the colocation group was not more medically ill than the mental-health group on key metabolic measures, including mean body mass index (colocation = 27.8 vs mental-health = 28.7, P =.392), low-density liprotein (colocation = 110.0 vs mental-health = 104.4, P =.480), and glucose (colocation = 94.1 vs mental-health = 109.2, P =.059). The most common medical disorders in the colocation group were related to metabolic syndrome. Conclusions: Colocated

primary care services were allocated on the basis of severity of psychiatric impairment rather than severity of medical illness. This program serves as a model for other systems to employ for integrated primary and behavioral health services for patients with serious mental illness. © 2013 Physicians Postgraduate Press, Inc.

Teeluckdharry, S., Sharma, S., O'Rourke, E., et al. 2013. Monitoring metabolic side effects of atypical antipsychotics in people with an intellectual disability. Journal of Intellectual Disabilities 17(3) 223-35.

This audit was undertaken prospectively to examine the compliance of a group of psychiatrists against guidelines they developed for monitoring the onset of metabolic syndrome, a potential side effect of antipsychotic medication, especially second generation or atypical ones. Phase 1 of the audit was to set standards by a questionnaire survey of participating psychiatrists against Consensus Guidelines on monitoring (American Diabetic Association, 2004), which they favoured. The results led to modifying these guidelines to develop minimum acceptable standards against which their practice was audited in Phase 2. Although in Phase 1, 77% of the psychiatrists felt that they did some baseline recording, Phase 2 finding did not corroborate this--only 53.8% of the notes recorded the assessment of risk factors in personal history; 37.5% risk factors in family history; 31.7% baseline weight and 26.4% baseline blood sugar/lipid levels. In Phase 1, 85% of the psychiatrists thought that they carried out some of the recommended monitoring; our audit found the records of weight monitoring in 69.7% of the notes and blood sugar and lipids monitoring in 44.2%. People with intellectual disability have a shorter life expectancy and increased risk of early death when compared with the general population. Obesity is already a health issue for people with intellectual disability. We discuss the challenges faced by psychiatrists in implementing their own minimum acceptable standards and suggest measures to reduce the metabolic risk associated with antipsychotic medication through increasing awareness--use of information leaflets in accessible format, health promotion and use of side effect checklists and improving access--by working collaboratively with general practitioners utilising the forum of annual health checks.

Udo, T., McKee, S. A., White, M. A., et al. 2013. Sex differences in biopsychosocial correlates of binge eating disorder: a study of treatment-seeking obese adults in primary care setting. General Hospital Psychiatry 35(6) 587-91.

OBJECTIVE: Although community-based studies suggest equivalent levels of physical and psychological impairment by binge eating disorder (BED) in men and women, men with BED are still underrepresented in clinical studies. This study aimed to provide a comprehensive analysis of sex differences in biopsychosocial correlates of treatment-seeking obese patients with BED in primary care.METHOD: One hundred-ninety obese adults (26% men) were recruited in primary care settings for a treatment study for obesity and BED.RESULTS: Very few significant sex differences were found in the developmental history and in current levels of eating disorder features, as well as psychosocial factors. Women reported significantly earlier age at onset of overweight and dieting

and greater frequency of dieting. Men reported more frequent strenuous exercise. Men were more likely than women to meet criteria for metabolic syndrome; men were more likely to show clinically elevated levels of triglycerides, blood pressure, and fasting glucose levels.CONCLUSION: Despite few sex differences in behavioral and psychosocial factors, metabolic problems associated with obesity were more common among treatment-seeking obese men with BED than women. The findings highlight the importance of including men in clinical studies of BED and active screening of BED in obese men at primary care settings.

Coakley, C., Bolton, P., Flaherty, L., et al. 2012. The incidence of metabolic risk factors in an inpatient psychiatric setting. Journal of Psychosocial Nursing & Mental Health Services 50(3) 24-30.

Our study examines risk factors for metabolic syndrome on admission to an acute psychiatric facility and the incidence of medical referrals at discharge. Data on demographics, risk factors for metabolic syndrome, other health risk factors, medications, related diagnoses, and primary care providers and referrals were collected from 125 psychiatric patient charts. Comparison analysis was done for two groups: those with two or more risk factors for metabolic syndrome and those with less than two risk factors. Differences between groups were statistically significant for age, waist circumference, body mass index, high-density lipoprotein, triglycerides, and fasting glucose levels. Few patients were referred to their primary care provider for follow-up care. This study has clinical implications for improving assessment of psychiatric patients at risk for developing metabolic syndrome, for designing interventions to help patients adopt lifestyle changes to mitigate these risks, and for working toward fuller integration of psychiatric and primary care.

Freeman, C. P. & Joska, J. A. 2012. Dealing with major depression in general practice. South African Family Practice 54(3) 203-209.

One in ten South Africans will be diagnosed with major depressive disorder (MDD) at some point in their lives. MDD is a potentially disabling condition that affects many spheres of an individual's life and leads to marked social and occupational dysfunction. General practitioners are frequently required to diagnose and manage MDD, often in a time-pressured primary healthcare setting. This article aims to provide practitioners with an overview of MDD. It covers aspects of diagnosis, co-morbidity, pharmacology and special patient groups. Copyright © 2012, © 2012 SAAFP. Published by Medpharm.

Galon, P. & Graor, C. H. 2012. Engagement in primary care treatment by persons with severe and persistent mental illness. Archives of Psychiatric Nursing 26(4) 272-84.

Even when primary care provider relationships exist, persons with severe and persistent mental illness (SPMI) are more likely to be undertreated and seek care from emergency room settings. The purpose of this study was to describe the social process of engagement in primary care treatment from the perspective of persons with SPMI. Using grounded theory and semistructured interviews, 32 adults were

interviewed. The process of engagement includes mattering, being perceived as credible and capable, and working together. Clinical, education, and research implications are discussed. Future studies should explore engagement in primary care with this population from the perspective of providers.

Halfon, N., Verhoef, P. A. & Kuo, A. A. 2012. Childhood antecedents to adult cardiovascular disease. Pediatrics in Review 33(2) 51-61.

* Through research in the prevention and treatment of adult diseases, it has become clear that many adult diseases have their origins in childhood. As illustrated in this review, these antecedents are largely a function of the nutrition, physical activity, and habits of developing children. * There is also increasing evidence that chronic and toxic levels of stress can play a significant role not only in the development of mental and behavioral conditions but in the developmental pathways that lead to a number of chronic physical health conditions. * Internists, family medicine physicians, and medicine-pediatrics physicians generally are comfortable managing patients with a number of cardiovascular risk factors or conditions. Although pediatric clinical guidelines have recommended universal screening for hypertension since 1977 and targeted screening for dyslipidemia since 1992 and type 2 DM since 2000, this screening is not yet common practice in general pediatrics. * As the population of children and youth with risk factors for metabolic syndrome - hypertension, dyslipidemia, and type 2 DM - increases as a result of the obesity epidemic, pediatricians will have to screen routinely, and diagnose and treat these conditions in the primary care setting. * Pediatric residency programs and continuing medical education programs will have to provide knowledge and clinical training in the management of these conditions before primary care pediatricians are comfortable treating children and youth with multiple cardiovascular conditions.

Kahl, K. G., Greggersen, W., Schweiger, U., et al. 2012. Prevalence of the metabolic syndrome in unipolar major depression. European Archives of Psychiatry & Clinical Neuroscience 262(4) 313-20.

Previous studies on the association between affective disorders and the metabolic syndrome yielded inconclusive results. Therefore, we examined the prevalence of the metabolic syndrome in 230 men and women with unipolar major depressive disorder during inpatient treatment and compared it to 1,673 subjects from primary care from a similar region in northern Germany. We used the AHA/NHBLI criteria to determine the rate of metabolic syndrome (MetS) and each single criterion of MetS in both groups. The age-standardized prevalence of MetS was 2.4x as high in patients with major depressive disorder (MDD) compared with data from comparison subjects (41.0% vs. 17.0%). With respect to the single criteria, elevations were found in MDD patients for fasting glucose and triglycerides in both genders, and waist circumference in women. Men in the patient and the comparison groups were found to have higher rates of increased fasting glucose and triglycerides than women in the respective groups. Factors associated with the MetS in MDD patients comprise body mass index and the severity of depression. Our results demonstrate an increased prevalence of the MetS in men and women with

MDD. Interventions for the frequently untreated metabolic abnormalities and careful screening for physical health conditions among people with MDD are warranted.

Robichaud-Halle, L., Beaudry, M. & Fortin, M. 2012. Obstructive sleep apnea and multimorbidity. BMC Pulmonary Medicine 12 (no pagination)(60).

Background: Obstructive sleep apnea (OSA) is becoming increasingly prevalent in North America and has been described in association with specific chronic diseases, particularly cardiovascular diseases. In primary care, where the prevalence of co-occurring chronic conditions is very high, the potential association with OSA is unknown. The purpose of this study was to explore the association between OSA and 1) the presence and severity of multimorbidity (multiple co-occurring chronic conditions), and 2) subcategories of multimorbidity.Methods: A cluster sampling technique was used to recruit 120 patients presenting with OSA of various severities from the records of a sleep laboratory in 2008. Severity of OSA was based on the results of the polysomnography. Patients invited to participate received a mail questionnaire including questions on sociodemographic characteristics and the Disease Burden Morbidity Assessment (DBMA). They also consented to give access to their medical records. The DBMA was used to provide an overall multimorbidity score and sub-score of diseases affecting various systems.Results: Bivariate analysis did not demonstrate an association between OSA and multimorbidity (r = 0.117; p = 0.205). However, severe OSA was associated with multimorbidity (adjusted odds ratio = 7.33 [1.67-32.23], p = 0.05). OSA was moderately correlated with vascular (r = 0.26, p = 0.01) and metabolic syndrome (r = 0.26, p = 0.01) multimorbidity sub-scores.Conclusions: This study showed that severe OSA is associated with severe multimorbidity and sub-scores of multimorbidity. These results do not allow any causal inference. More research is required to confirm these associations. However, primary care providers should be aware of these potential associations and investigate OSA when deemed appropriate. © 2012 Robichaud-Halle et al.; licensee BioMed Central Ltd.

Sweileh, W. M., Zyoud, S. H., Dalal, S. A., et al. 2012. Prevalence of metabolic syndrome among patients with schizophrenia in Palestine. BMC Psychiatry 12 235.

BACKGROUND: Metabolic syndrome (MS) is a cluster of the most dangerous cardiac risk factors and is associated with high mortality. Ethnic differences in metabolic syndrome (MS) criteria and prevalence rates have been reported. The purpose of this study was to investigate the MS prevalence among patients with schizophrenia in Palestine.METHODS: We recruited 250 patients with schizophrenia from 4 psychiatric primary healthcare centers in Northern Palestine. The MS prevalence was assessed based on National Cholesterol Education Program Adult Treatment Panel III Adapted criteria.RESULTS: The overall MS prevalence was 43.6%, with 39% in male and 55.9% in female patients. On average, the study patients had 2.3+/-1.3 metabolic abnormalities. Univariate analysis showed that MS was significantly higher with older age, female gender, longer duration of the illness, smoking, abdominal obesity, high

systolic and diastolic blood pressure, high triglycerides, low HDL-C, and high fasting plasma glucose. Multiple logistic regression analysis showed that only systolic blood pressure, high triglycerides, high fasting plasma glucose, and low HDL-C were significant predictors of MS in schizophrenic patients.CONCLUSIONS: MS is common among Arab patients with schizophrenia. Patients with schizophrenia should receive regular monitoring and adequate treatment of cardio-metabolic risk factors.

Viron, M., Baggett, T., Hill, M., et al. 2012. Schizophrenia for primary care providers: How to contribute to the care of a vulnerable patient population. American Journal of Medicine 125(3) 223-230.

Patients with schizophrenia represent a vulnerable population with high medical needs that are often missed or undertreated. Primary care providers have the potential to reduce health disparities experienced by this population and make a substantial difference in the overall health of these patients. This review provides primary care providers with a general understanding of the psychiatric and medical issues specific to patients with schizophrenia and a clinically practical framework for engaging and assessing this vulnerable patient population and assisting them in achieving optimal health. Initial steps in this framework include conducting a focused medical evaluation of psychosis and connecting patients with untreated psychosis to psychiatric care as promptly as possible. Given the significant contribution of cardiovascular disease to morbidity and mortality in schizophrenia, a top priority of primary care for patients with schizophrenia should be cardiovascular disease prevention and treatment through regular risk factor screening, appropriate lifestyle interventions, and other indicated therapies. © 2012 Elsevier Inc. All rights reserved.

Agyapong, V. I. O., Farren, C. K. & McLoughlin, D. M. 2011. Mobile Phone Text Message Interventions in Psychiatry - what are the possibilities? Current Psychiatry Reviews 7(1) 50-56.

There has been a global surge in the use of mobile phones over the past decade with subscription rates of devices in Europe now exceeding 100%. Mobile phones are popular, portable and affordable, and allow for easy communication. This provides an opportunity for their use in improving mental health related outcomes, especially through use of text message technology. Several studies have demonstrated the usefulness of text messages in improving various aspects of medical care, including attendance with primary care and outpatient clinic appointments, adherence with physical health medication, managing side effects of non-psychotropic medication and promoting smoking cessation. We review here the potential for using text message technology in psychiatry, specifically for improving adherence with scheduled outpatient appointments, increasing adherence with psychotropic medication, managing side effects of psychotropic medication and managing patients with addictive disorders and co-morbid mental health problems. We identify barriers to the potential use of text messaging technology in psychiatry and propose solutions to some of these barriers. We also propose the need for further research into the use of text messaging in psychiatry and how this might

impact upon the therapeutic relationship with patients. © 2011 Bentham Science Publishers Ltd.

Barnes, R. D., Boeka, A. G., McKenzie, K. C., et al. 2011. Metabolic syndrome in obese patients with binge-eating disorder in primary care clinics: A cross-sectional study. Primary Care Companion to the Journal of Clinical Psychiatry 13(2).

Background: The distribution and nature of metabolic syndrome in obese patients with binge-eating disorder (BED) are largely unknown and require investigation, particularly in general internal medicine settings. The objectives of this study were to (1) examine the frequency of metabolic syndrome and (2) explore its eating- and weight-related correlates in obese patients with BED. Method: This was a cross-sectional analysis of 81 consecutive treatment-seeking obese (body mass index >= 30 kg/m²) patients (21 men, 60 women) who met DSM-IV-TR research criteria for BED (either subthreshold criteria: >= 1 binge weekly, n = 19 or full criteria: >= 2 binges weekly, n = 62). Participants were from 2 primary care facilities in a large university-based medical center in an urban setting. Patients with and without metabolic syndrome were compared on demographic features and current and historical eating- and weight-related variables. Data were collected from December 2007 through March 2009. Results: Forty-three percent of patients met criteria for metabolic syndrome. A significantly higher proportion of men (66%) than women (35%) met criteria for metabolic syndrome (P =.012). Patients with versus without metabolic syndrome did not differ significantly in ethnicity or body mass index. Patients with versus without metabolic syndrome did not differ significantly in binge-eating frequency, severity of eating disorder psychopathology, or depression. Analyses of covariance controlling for gender revealed that patients without metabolic syndrome started dieting at a significantly younger age (P =.037), spent more of their adult lives dieting (P =.017), and reported more current dietary restriction (P =.018) than patients with metabolic syndrome. Conclusions: Metabolic syndrome is common in obese patients with BED in primary care settings and is associated with fewer dieting behaviors. These findings suggest that certain lifestyle behaviors, such as increased dietary restriction, may be potential targets for intervention with metabolic syndrome. © Copyright 2011 Physicians Postgraduate Press, Inc.

Larsen, J. T., Fagerquist, M., Holdrup, M., et al. 2011. Metabolic syndrome and psychiatrists' choice of follow-up interventions in patients treated with atypical antipsychotics in Denmark and Sweden. Nordic Journal of Psychiatry 65(1) 40-6.

INTRODUCTION: The aim of the present study was to obtain point prevalence estimates of the metabolic syndrome according to the NCEP III criteria in a sample of patients with schizophrenia spectrum disorders treated with atypical antipsychotic drugs in Denmark and Sweden, and to assess the psychiatrists' choice of recommendations for follow-up interventions based on the patients' laboratory results.METHOD: This was a cross-sectional, observational multi-center study in Denmark and Sweden, in consecutively screened in- and outpatients with schizophrenia

spectrum disorders and continuously treated for at least 3 months with atypical antipsychotic drugs.RESULTS: The metabolic syndrome as per medical history was present in 1% of 582 evaluable patients at baseline. After performing laboratory measurements and applying the NCEP III criteria, metabolic syndrome was confirmed in 43% of subjects. The high rate of metabolic syndrome did not elicit much decisive action on the part of the treating psychiatrists; the most frequent action taken was dietary and exercise advice (in 75% of subjects), while in 54% and 19% of subjects a laboratory follow-up and blood pressure follow-up were advised respectively. Change of antipsychotic medication was recommended in only 10% of patients, and in further 11% of patients, no action was taken.CONCLUSION: Observed metabolic syndrome prevalence rates were at least twice the rates observed in a normal, non-diabetic population. It appears that in this vulnerable population of patients with schizophrenia spectrum disorders, metabolic syndrome remains underdiagnosed and undertreated.

Londhe, S. S. 2011. A major health hazard: Metabolic syndrome. International Journal of Pharmacy and Pharmaceutical Sciences 3(3) 1-8.

The constellation of dyslipidemia (hypertriglyceridemia and low levels of high-density lipoprotein cholesterol), elevated blood pressure, impaired glucose tolerance, and central obesity is identified now as metabolic syndrome, also called syndrome X. Soon, metabolic syndrome will overtake cigarette smoking as the number one risk factor for heart disease among the U.S. population. The National Cholesterol Education Program-Adult Treatment Panel III has identified metabolic syndrome as an indication for vigorous lifestyle intervention. Effective interventions include diet, exercise, and judicious use of pharmacologic agents to address specific risk factors. Weight loss significantly improves all aspects of metabolic syndrome. Increasing physical activity and decreasing caloric intake by reducing portion sizes will improve metabolic syndrome abnormalities, even in the absence of weight loss. Specific dietary changes that are appropriate for addressing different aspects of the syndrome include reducing saturated fat intake to lower insulin resistance, reducing sodium intake to lower blood pressure, and reducing high-glycemic-index carbohydrate intake to lower triglyceride levels. A diet that includes more fruits, vegetables, whole grains, monounsaturated fats, and low-fat dairy products will benefit most patients with metabolic syndrome. Family physicians can be more effective in helping patients to change their lifestyle behaviors by assessing each patient for the presence of specific risk factors, clearly communicating these risk factors to patients, identifying appropriate interventions to address specific risks, and assisting patients in identifying barriers to behavior change.

Udo, I., Mooney, M. & Newman, A. 2011. Prevalence of obesity and metabolic syndrome in a long-stay psychiatric unit. Irish Journal of Psychological Medicine 28(4) 205-208.

Objective: The aim of this study was to determine the prevalence of metabolic syndrome and obesity as defined by Body Mass Index (BMI) in a long-stay psychiatric unit where all care is provided by the psychiatric team. M ethod: All

residents in this long-stay unit were screened. Their BMI was calculated. Waist circumference and blood investigations were done. Ward records were used to determine those who had been previously diagnosed with hypertension and diabetes. The ATP 111 criteria were used to determine the prevalence of metabolic syndrome. Results: We found a prevalence of 33% for BMI obesity and a prevalence of 66% for metabolic syndrome. These are higher than those of the general Irish middle aged population and the accepted estimate of a general psychiatric population. It is also higher than that of a previous published study on an Irish long-stay psychiatric ward population. Conclusion: There is high prevalence of BMI obesity and metabolic syndrome in long-stay psychiatric residents. This has the potential to impact significantly on physical morbidity and mortality. People with severe and enduring mental illness should have access to primary care and other health services on the same basis as any other citizen.

Vetter, M. L., Wadden, T. A., Lavenberg, J., et al. 2011. Relation of health-related quality of life to metabolic syndrome, obesity, depression and comorbid illnesses. International Journal of Obesity 35(8) 1087-1094.

Background:Metabolic syndrome has been associated with impaired health-related quality of life (HRQoL) in several studies. Many studies used only one HRQoL measure and failed to adjust for important confounding variables, including obesity, depression and comorbid conditions.Objective:To investigate the relationship between metabolic syndrome and HRQoL using multiple measures. We also sought to determine whether increasing body mass index or diabetes status further modified this relationship.Methods:This cross-sectional study included 390 obese participants with elevated waist circumference and at least one other criterion for metabolic syndrome. Of these 390 participants, 269 had metabolic syndrome (that is, they met 3 out of the 5 criteria specified by the NCEP (National Cholesterol Education Program)) and 121 did not. Participants were enrolled in a primary care-based weight-reduction trial. HRQoL was assessed using two generic instruments, the Medical Outcomes Study Short-Form 12 and the EuroQol-5D, as well as an obesity-specific measure, the Impact of Weight on Quality of Life. Differences in HRQoL were compared among participants with and without metabolic syndrome. Multivariable linear regression was used to determine how HRQoL varied according to metabolic syndrome status, and whether factors including weight, depression and burden of comorbid disease modified this relationship.Results:Metabolic syndrome was not associated with HRQoL as assessed by any of the measures. In univariable analysis, depression, disease burden and employment status were significantly associated with worse HRQoL on all instruments. In multivariable models, only depression remained significantly associated with reduced HRQoL on all measures. Increasing obesity and diabetes status did not modify the relationship between metabolic syndrome and HRQoL.Conclusion:In contrast to previous studies, metabolic syndrome was not associated with impaired HRQoL as assessed by multiple measures. This suggests that metabolic syndrome in itself is not associated with decreased HRQoL, but other factors such as obesity, depression and greater disease burden may significantly influence the quality of life in this population. © 2011 Macmillan Publishers Limited All rights reserved.

Druss, B. G., von Esenwein, S. A., Compton, M. T., et al. 2010. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. American Journal of Psychiatry 167(2) 151-9.

OBJECTIVE: Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings.METHOD: A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care.RESULTS: At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%).CONCLUSIONS: Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

Ferreira, L., Belo, A. & Abreu-Lima, C. 2010. A case-control study of cardiovascular risk factors and cardiovascular risk among patients with schizophrenia in a country in the low cardiovascular risk region of Europe. Revista Portuguesa de Cardiologia 29(10) 1481-1493.

Introduction: Patients with serious mental illness have increased cardiovascular risk factors and excess mortality from cardiovascular disease that are in part favored by adverse effects of treatment. Given the wide geographical variation of vascular atherosclerotic disease there is a recognized need for national studies. Methods: The prevalence of risk factors and estimated absolute and relative cardiovascular risk by means of SCORE risk charts were ascertained in 125 schizophrenia out-patients and 1721 age- and gender-matched primary care center users. Results: Patients with schizophrenia have a very high prevalence of cardiovascular risk factors. Higher values were observed for smoking (65.0%), clinical or laboratory dyslipidemia (59.1% and 52.0%), careless diet (78.4%), sedentary lifestyle (64.2%), overweight or obesity (64.2%) and abdominal obesity

(50.9%). Lower values were observed for hypertension (25.0%), metabolic syndrome (21.9%), diabetes (9.6%) and alcohol abuse (4.0%). An association between risk factor exposure and disease was documented (odds ratio, [95% confidence limits]) for smoking (2.47 [1.68-3.64]), laboratory dyslipidemia (1.92 [1.33-2.77]), low HDL-C (2.12 [1.31-3.42]), careless diet (4.46 [2.88-6.90]) and sedentary lifestyle (1.79 [1.22-2.62]). A significant association between antipsychotics that are more likely to induce weight gain and overweight or obesity could not be demonstrated in this study. Hypertension was 46% lower in cases (n=26/125) than in controls (0.54 [0.34-0.84]). This rather surprising result could be explained by our finding of a negative association (p=0.01) between blood pressure levels and rate of benzodiazepine prescription among schizophrenia patients. The negative association documented in these patients by multivariate regression analysis (p=0.005) between hypertension and benzodiazepine prescription reinforces this explanation. Untreated hypertension, untreated dyslipidemia and untreated diabetes are strongly associated with schizophrenia (3.79 [1.63-8.81]), (3.79 [2.06-7.35]), (6.38 [1.725-23.59]), respectively. A significant difference in 10-year absolute risk of fatal cardiovascular disease between cases and controls aged 40 years or more could not be demonstrated in our study (p=0.054). Nonetheless, in younger individuals, higher levels of relative risk multiples in the 2-12 range were found in schizophrenia patients compared to controls (p<0.050). Conclusions: In schizophrenia patients, a high prevalence of cardiovascular risk factors and of neglected treatment was found. The great majority of cases and controls aged 40 years or more have low and comparable levels of absolute cardiovascular risk mortality. For those aged under 40 years, schizophrenia patients show higher relative cardiovascular risk than controls. These findings call for closer collaboration between psychiatrists and primary care providers. The finding of a lower prevalence of hypertension among cases seems to be associated with an apparent protective effect of benzodiazepines, which are frequently prescribed to patients with schizophrenia in Portugal.

Graves, B. W. 2010. The obesity epidemic: Scope of the problem and management strategies. Journal of Midwifery and Women's Health 55(6) 568-578.

As the obesity epidemic increases, primary care clinicians are encountering obesity and health problems associated with obesity more frequently than ever before. In 2007, 41% of women were classified as obese, with a body mass index (BMI) of 30 or higher. Non-Hispanic blacks and Hispanics are more likely to be obese than white, non-Hispanics. A wide spectrum of health problems has been associated with obesity, including cardiovascular disease, diabetes, metabolic syndrome, osteoarthritis, and polycystic ovary syndrome. Obesity has been shown to be a low-grade inflammatory state, which may be responsible for many of the comorbidities. The general consensus recommends screening for obesity and counseling to promote weight loss. In some cases, pharmacotherapy and or bariatric surgery may be recommended. © 2010 American College of Nurse-Midwives.

Holt, R. I. G. & Peveler, R. C. 2010. Diabetes and cardiovascular risk in severe mental illness: A missed opportunity and challenge for the future. Practical Diabetes International 27(2) 79-84ii.

Schizophrenia and bipolar illness are severe mental illnesses that affect around 1-2% of the population. They are associated with premature mortality with a reduced life-expectancy of 10-20 years. Although suicide and trauma contribute the highest relative risk of mortality, physical illness accounts for around three-quarters of all deaths, with cardiovascular disease being the most common cause of death. Traditional cardiovascular risk factors including diabetes, dyslipidaemia, obesity and smoking are all more common in people with severe mental illness (SMI). Although there has been an increasing awareness of physical health issues in people with SMI, the level of screening for and management of cardiovascular risk factors has remained low. A number of national and international bodies have developed guidelines to address the challenge of physical morbidity in SMI. The principles of screening for and managing cardiovascular disease in people with SMI are similar to those in the general population, but there are additional challenges. Health care professionals within psychiatry, general practice and medical specialties need to work together to reduce the burden of physical health problems in people with SMI. Copyright © 2010 John Wiley & Sons.

Kahl, K. G., Greggersen, W., Schweiger, U., et al. 2010. Prevalence of the metabolic syndrome in men and women with alcohol dependence: results from a cross-sectional study during behavioural treatment in a controlled environment. Addiction 105(11) 1921-7.

AIMS: Prevalence of metabolic syndrome (MetS) in men and women who use alcohol has been inconsistent in the literature. The aim of this study is to compare the prevalence of MetS in patients with a diagnosis of alcohol dependence who are currently abstinent in a controlled environment, and in control subjects followed in primary care from a similar region in Northern Germany.DESIGN: Cross-sectional study.SETTING: In-patient cognitive behavioural therapy.PARTICIPANTS: One hundred and ninety-seven men and women with alcohol dependence during behavioural treatment in a controlled environment were compared to 1158 subjects from primary care from a similar region in northern Germany.MEASUREMENTS: We used the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHBLI) criteria to determine the rate of MetS and each single criterion of MetS in both groups.FINDINGS: The prevalence of MetS was almost twice as high in men and women with alcohol dependence compared to control subjects (30.6% versus 17.0%). With respect to the single criteria, elevations were found for fasting glucose and blood pressure in both genders and for triglycerides in women only. High density lipoprotein (HDL)-cholesterol was higher in men and women with alcohol dependence.CONCLUSIONS: Our results demonstrate an increased rate of MetS, increased blood pressure and dysregulation of glucose and lipid metabolism in alcohol-dependent patients. Whether high HDL-cholesterol has cardioprotective effects in this context remain doubtful.

Ketter, T. A. 2010. Strategies for monitoring outcomes in patients with bipolar disorder. Primary Care Companion to the Journal of Clinical Psychiatry 12(SUPPL. 1) 10-16.

Practical strategies are available for primary care physicians to monitor psychiatric and medical outcomes as well as treatment adherence in patients with bipolar disorder. Current depressive symptoms can be assessed with tools like the 9-item Patient Health Questionnaire or Beck Depression Inventory. Lifetime presence or absence of manic or hypomanic symptoms can be assessed using the Mood Disorder Questionnaire (MDQ). These measures can be completed quickly by patients prior to appointments. Sensitivity of such ratings, particularly the MDQ, can be increased by having a significant other also rate the patient. Clinicians should also screen mood disorder patients for psychiatric comorbidities that are common in this population such as anxiety and substance use disorders. While patients with bipolar disorder may commonly be nonadherent with prescribed medication regimens, strategies that can help include having frank discussions with the patient, selecting medication collaboratively, adding psychotherapy with a psychoeducation element, monitoring appointment-keeping, using patient self-reports of medication-taking, enlisting the aid of significant others, and measuring plasma drug levels. Medical monitoring is needed to assess the safety and tolerability of psychotropic medications. All of the approved medications for bipolar disorder have at least 1 boxed warning for serious side effects, but are also associated with other common management-limiting side effects such as sedation, tremor, unsteadiness, restlessness, nausea, vomiting, diarrhea, constipation, weight gain, and metabolic problems. Routine monitoring is particularly needed for obesity, metabolic syndrome, and cardiovascular disorders, which lead to high rates of medical morbidity and mortality in patients with bipolar disorder. Monitoring protocols such as the one recommended by the American Diabetes Association for patients taking second-generation antipsychotics can be used for regular assessment. © 2010 Physicians Postgraduate Press, Inc.

Lamers, F., de Jonge, P., Nolen, W. A., et al. 2010. Identifying depressive subtypes in a large cohort study: results from the Netherlands Study of Depression and Anxiety (NESDA). Journal of Clinical Psychiatry 71(12) 1582-9.

OBJECTIVE: The heterogeneity of depression in the current classification system remains a point of discussion in the psychiatric field, despite previous efforts to subclassify depressive disorders. Data-driven techniques may help to come to a more empirically based classification. This study aimed to identify depressive subtypes within a large cohort of subjects with depression.METHOD: Baseline data from 818 persons with a DSM-IV diagnosis of current major depressive disorder or minor depression who participated in the Netherlands Study of Depression and Anxiety were used. Respondents were recruited in the community, in primary care, and in specialized mental health care from September 2004 through February 2007. Latent classes were derived from latent class analysis using 16 depressive symptoms from the Composite International Diagnostic Interview and the Inventory of Depressive Symptomatology. Classes were

characterized using demographic, clinical psychiatric, psychosocial, and physical health descriptors.RESULTS: Three classes were identified: a severe melancholic class (prevalence, 46.3%), a severe atypical class (prevalence, 24.6%), and a class of moderate severity (prevalence, 29.1%). Both severe classes were characterized by more neuroticism (melancholic OR = 1.05 [95% CI, 1.01-1.10]; atypical OR = 1.07 [95% CI, 1.03-1.12]), more disability (melancholic OR = 1.07 [95% CI, 1.05-1.09]; atypical OR = 1.06 [95% CI, 1.04-1.07]), and less extraversion (melancholic OR = 0.95 [95% CI, 0.92-0.99]; atypical OR = 0.95 [95% CI, 0.92-0.99]) than the moderate class. Comparing the melancholic class with the atypical class revealed that the melancholic class had more smokers (atypical OR = 0.57 [95% CI, 0.39-0.84]) and more childhood trauma (atypical OR = 0.86 [95% CI, 0.74-1.00]), whereas the atypical class had more women (atypical OR = 1.52 [95% CI, 0.99-2.32]), a higher body mass index (atypical OR = 1.13 [95% CI, 1.09-1.17]), and more metabolic syndrome (atypical OR = 2.17 [95% CI, 1.38-3.42]).CONCLUSIONS: Both depression severity (moderate vs severe) and the nature of depressive symptoms (melancholic vs atypical) were found to be important differentiators between subtypes. Higher endorsement rates of somatic symptoms and more metabolic syndrome in the atypical class suggest the involvement of a metabolic component.

Millar, H. L. 2010. Development of a health screening clinic. European Psychiatry: the Journal of the Association of European Psychiatrists 25 Suppl 2 S29-33.

Medical morbidity and mortality levels remain elevated in people with schizophrenia compared with the general population. Despite the increasing recognition of an excess of physical health problems in this population, health screening remains limited. Medical risk in this population can be related to a variety of sources. The disease process itself as well as poor diet and sedentary lifestyle contribute to the overall physical health problems. In addition antipsychotic medication can contribute to the risk of cardiovascular and metabolic problems. The Dundee Health Screening Clinic was developed to address the needs of this population by monitoring physical health and providing follow-up to ensure that patients received the necessary care. The Clinic demonstrates how a coordinated approach can be used to take simple steps to improve the overall well-being of these patients. It was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. Simple clinical measurements and tests were conducted in the Clinic and patients clearly demonstrated on a satisfaction questionnaire that they considered the health checks important. This Clinic is an example of how a holistic approach can impact on both the physical and mental well-being of patients and offer them improved care and therefore a better quality of life.

Schmidt, D., Anderson, L., Bingen, K., et al. 2010. Late effects in adult survivors of childhood cancer: Considerations for the general practitioner. Wisconsin Medical Journal 109(2) 98-108.

Childhood cancer survivorship is a national public health priority, with an increasing number of survivors who face late effects from both disease and treatment. As childhood cancer survivors are living into adulthood, care of the late effects associated with their diagnosis and treatment can become complex. Often these patients no longer have follow-up with the treating pediatric hospital and seek medical care from an adult primary care professional. Combining the results of current survivorship research with clinical experience, we describe common late effects that general internists and primary care professionals may encounter during routine visits with adult survivors of childhood cancer. Recommendations and resources are provided for identifying and managing late effects.

Bell, P. F., McKenna, J. P. & Roscoe, B. M. 2009. Treatment of bipolar disorders and metabolic syndrome: implications for primary care. Postgraduate Medicine 121(5) 140-4.

Recognition of the prevalence of mood disorders and increased availability of medication options have led to calls for treating bipolar disorders in the primary care setting. Second-generation antipsychotic medications (SGAs) were initially lauded for treating bipolar disorders because of their efficacy and perceived safety relative to first-generation antipsychotic medications. Metabolic syndrome is a constellation of risk factors for cardiovascular disease and type 2 diabetes mellitus, which may emerge when treating bipolar disorders with SGAs. We conducted a search of the research literature examining the association between different SGAs and metabolic syndrome. Based on our review, we offer guidelines for monitoring patient status regarding metabolic syndrome and for providing interventions to promote healthy diet and exercise. [References: 39]

Crabb, J., McAllister, M. & Blair, A. 2009. Who should swing the stethoscope? An audit of baseline physical examination and blood monitoring on new patients accepted by an early intervention in psychosis team. Early intervention in psychiatry 3(4) 312-6.

AIM: It has been established that patients with severe mental illness are at increased risk of physical illness and that physical health screening should be performed when an individual experiences a first episode of psychosis. The aim of the audit was to examine how physical health screening was achieved in the real world of an early intervention in psychosis (EIP) service in Scotland. Of particular interest was considering if primary or secondary care were more effective in providing specific physical health assessment for those presenting to the service.METHODS: A case note audit was performed.RESULTS: The audit shows that physical examination and blood tests were being completed in the majority of service users under the care of the Esteem service. However, an unacceptably high number were not undergoing sufficient initial screening for metabolic syndrome or having baseline monitoring prior to commencing antipsychotic medication.CONCLUSIONS: Our results suggest that relying on primary care to provide physical health screening was not an effective approach in a population experiencing first-episode psychosis. Having a psychiatrist motivated to perform physical health

screening within the EIP team may help to improve the uptake of physical health screening. Strategies to improve physical health screening in EIP services are discussed.

Hasnain, M., Vieweg, W. V. R., Fredrickson, S. K., et al. 2009. Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications. Primary Care Diabetes 3(1) 5-15.

Individuals with major mental illness are a high-risk group for cardio-metabolic derangements due to genetic predisposition, developmental and environmental stressors, and lifestyle. This risk is compounded when they receive antipsychotic medications. Guidelines for screening, monitoring, and managing these patients for metabolic problems have been in place for several years. Despite this, recent reports document that this population continues to receive poor care in this regard. In this article, we review the metabolic profile of atypical antipsychotic medications and offer guidelines to reduce the metabolic complications of these agents. © 2008 Primary Care Diabetes Europe.

Kane, J. M. 2009. Creating a health care team to manage chronic medical illnesses in patients with severe mental illness: The public policy perspective. Journal of Clinical Psychiatry 70(SUPPL. 3) 37-42.

Patients with severe mental illnesses have higher morbidity rates and shorter life spans than the general population, due in part to modifiable risk factors. Psychiatrists should understand the increased health risks that patients with severe mental illness face due to their psychiatric diagnoses, personal health behaviors, and genetic risks, and how these risks are exacerbated by a fragmented health care system. Professional societies should develop guidelines for monitoring these health risks, and accrediting bodies should monitor adherence to these guidelines. Mental health providers should help improve the integration of primary care and mental health care and implement treatment strategies for changing modifiable health risk factors in their patients with severe mental illness. © Copyright 2009 Physicians Postgraduate Press, Inc.

Ludwick, J. J. & Oosthuizen, P. P. 2009. Screening for and monitoring of cardio-metabolic risk factors in outpatients with severe mental illness in a primary care setting. African Journal of Psychiatry (South Africa) 12(4) 287-292.

Objective: Recent findings suggest that premature death in patients with severe mental illness (SMI) can be attributed to the high comorbidity of cardio-metabolic disorders. This study investigated the prevalence and monitoring of some risk factors for cardio-metabolic disease in a cohort with SMI, compared to the general medical population. Method: 101 participants with SMI and 100 controls were recruited from a primary care clinic. Assessments of risk factors with standard clinical measurements were done after healthcare workers and patient-participants had completed the structured questionnaires. Clinical files were reviewed to determine frequency of monitoring of risk factors. Results: We found no differences between the groups in demographic variables. A similar prevalence of abnormal blood pressure (BP), increased Body Mass Index (BMI) and increased waist

circumference was noted in both groups. Females in both groups were more likely to have an abnormal waist circumference. Patients with SMI were significantly less likely to have recordings of their weight or BP in their clinic file. Healthcare workers and patients with SMI were largely unaware of the increased risk of cardio-metabolic illness. Conclusion: This study suggests that patients with SMI received poorer health monitoring than other patients attending a primary care clinic and that both healthcare workers and patients were poorly informed about the increased risk of cardio-metabolic disorders in patients with SMI.

Oud, M. J. & Meyboom-de Jong, B. 2009. Somatic diseases in patients with schizophrenia in general practice: their prevalence and health care. BMC Family Practice 10 32.

BACKGROUND: Schizophrenia patients frequently develop somatic co-morbidity. Core tasks for GPs are the prevention and diagnosis of somatic diseases and the provision of care for patients with chronic diseases. Schizophrenia patients experience difficulties in recognizing and coping with their physical problems; however GPs have neither specific management policies nor guidelines for the diagnosis and treatment of somatic co-morbidity in schizophrenia patients. This paper systematically reviews the prevalence and treatment of somatic co-morbidity in schizophrenia patients in general practice.METHODS: The MEDLINE, EMBASE, PsycINFO data-bases and the Cochrane Library were searched and original research articles on somatic diseases of schizophrenia patients and their treatment in the primary care setting were selected.RESULTS: The results of this search show that the incidence of a wide range of diseases, such as diabetes mellitus, the metabolic syndrome, coronary heart diseases, and COPD is significantly higher in schizophrenia patients than in the normal population. The health of schizophrenic patients is less than optimal in several areas, partly due to their inadequate help-seeking behaviour. Current GP management of such patients appears not to take this fact into account. However, when schizophrenic patients seek the GP's help, they value the care provided.CONCLUSION: Schizophrenia patients are at risk of undetected somatic co-morbidity. They present physical complaints at a late, more serious stage. GPs should take this into account by adopting proactive behaviour. The development of a set of guidelines with a clear description of the GP's responsibilities would facilitate the desired changes in the management of somatic diseases in these patients. [References: 39]

Rakel, R. E. 2009. Clinical and societal consequences of obstructive sleep apnea and excessive daytime sleepiness. Postgraduate Medicine 121(1) 86-95.

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although frequently undiagnosed, OSA is highly prevalent and presents most often with excessive daytime sleepiness (EDS). While obesity is the major predisposing factor, patients with OSA and EDS are at increased risk of other conditions, including cardiovascular disease, type 2 diabetes, cognitive impairment, and depression. Significant consequences include morbidity and mortality from the associated conditions in addition to personal and societal consequences of cognitive

impairment, such as driving and workplace accidents. Primary care physicians are ideally placed to screen for OSA and EDS in patients who present with commonly comorbid conditions such as obesity, cardiovascular disease, metabolic syndrome, and depression. Conversely, treatment of OSA and associated EDS might help alleviate significant comorbidities and their clinical and societal consequences. © Postgraduate Medicine.

Schneiderhan, M. E., Batscha, C. L. & Rosen, C. 2009. Assessment of a point-of-care metabolic risk screening program in outpatients receiving antipsychotic agents. Pharmacotherapy:The Journal of Human Pharmacology & Drug Therapy 29(8) 975-87.

STUDY OBJECTIVE: To assess the usefulness of a metabolic risk screening program, including point-of-care glucose testing, to quantify baseline metabolic risk in outpatients receiving antipsychotics.DESIGN: Retrospective, cross-sectional, cohort study.SETTING: University-affiliated department of psychiatry clinic.PATIENTS: A total of 92 adult outpatients (49 women, 43 men; mean +/- SD age 38.96 +/- 12 yrs) who were receiving antipsychotics and had undergone screening for metabolic syndrome at the clinic during 2004-2007.MEASUREMENTS AND MAIN RESULTS: Patient data were recorded on a metabolic screening checklist by a pharmacist or nurse. The checklist captured demographics, vital signs (height, weight, body mass index [BMI], blood pressure, waist and hip circumference, point-of-care random glucose level), personal and family knowledge of current illnesses (diabetes mellitus, hypertension, hyperlipidemia), modifiable risk factors (smoking, alcohol, level of activity), current drug therapy, and recommendations to the psychiatrist. The patient population who underwent screening included 49 African-Americans (53%), 21 Caucasians (23%), 16 Hispanics (17%), and 6 Asians (7%). Diagnoses were documented for 88 patients: schizophrenia or schizoaffective disorder in 53 patients (60%), and bipolar disorder and major depressive disorder was equally divided in the remaining 35 patients (40%). Of 89 patients (three patients had missing data on waist circumference), 63 (71%) met criteria for level 1 metabolic risk (abdominal obesity); of these 63 patients, 38 (60%) met criteria for level 2 risk (abdominal obesity plus hypertension). Patients with a random glucose level greater than 140 mg/dl had a higher likelihood for being at level 2 risk than level 1 risk (chi(2)=5.99, df=1, p=0.014). Women had a significantly higher likelihood for level 1 metabolic risk compared with men (chi(2)=5.99, df=1, p=0.019). African-Americans had a significantly higher likelihood of level 1 risk (p=0.026) and BMI greater than 30 kg/m(2) (p=0.003) compared with Caucasians. Patients with a BMI greater than 30 kg/m(2) had a significantly higher likelihood of diabetes (p=0.006), hypertension (p=0.03), and hyperlipidemia (p=0.05). Overall, 5 (5%) of the 92 patients met criteria for prediabetes risk.CONCLUSION: Point-of-care metabolic risk screening, done with a systematic interprofessional team approach, can provide clinicians with a practical method for identifying metabolic risk in patients prescribed antipsychotics.

Waterreus, A. J. & Laugharne, J. D. 2009. Screening for the metabolic syndrome in patients receiving antipsychotic treatment: a proposed algorithm. Medical Journal of Australia 190(4) 185-9.

The metabolic syndrome (MetS) is a well described cluster of interrelated risk factors for developing cardiovascular disease and type 2 diabetes. The key components of MetS are central obesity, hypertension, hyperglycaemia and dyslipidaemia. The 2005 International Diabetes Federation (IDF) consensus definition of MetS aimed to reduce confusion over criteria for MetS and to provide a simple diagnostic and clinical tool. There is considerable evidence to show that patients prescribed antipsychotic drugs are at increased risk of developing MetS. Existing clinical guidelines for metabolic screening of patients taking antipsychotics focus on diabetes rather than on the broader syndrome of MetS and are not consistent with the IDF definition of MetS. Monitoring for MetS in patients taking antipsychotics (both inpatients and outpatients) is generally poor. We present a user-friendly clinical algorithm and monitoring form, based on current evidence and using the IDF definition of MetS, to help clinicians in primary care or specialist settings to effectively monitor for MetS in these patients. [References: 24]

Arango, C., Bobes, J., Aranda, P., et al. 2008. A comparison of schizophrenia outpatients treated with antipsychotics with and without metabolic syndrome: findings from the CLAMORS study. Schizophrenia Research 104(1-3) 1-12.

OBJECTIVE: To compare clinical, laboratory, lifestyle, and sociodemographic parameters and cardiac risk in antipsychotic-treated patients with and without metabolic syndrome (MS).METHODS: A multicenter cross-sectional study in which 117 psychiatrists recruited antipsychotic-treated outpatients meeting DSM-IV criteria for schizophrenia, schizophreniform or schizoaffective disorder. MS was diagnosed when 3 or more of the following criteria were met: waist circumference > 102 cm (men)/> 88 cm (women); serum triglycerides > or = 150 mg/dl; HDL cholesterol < 40 mg/dl (men)/< 50 mg/dl (women); blood pressure > or = 130/85 mmHg; fasting blood glucose > or = 110 mg/dl. The 10-year cardiovascular (CV) risk was assessed by the Systematic COronary Risk Evaluation (SCORE) function (CV mortality) and the Framingham function (any-CV-event).RESULTS: 1452 evaluable patients (863 men, 60.9%), aged 40.7+/-12.2 years and with a mean duration of illness of 15.5+/-10.8 years (mean+/-SD), were included. MS was present in 24.6% [23.6% (men), 27.2% (women); p=0.130]. Overall 10-year risks were 0.9+/-1.9 (SCORE) and 7.2+/-7.6 (Framingham). Coronary heart disease (CHD) 10-year risk was higher in MS patients: 6.6% vs 2.8% showed high/very-high CV mortality risk (SCORE > or = 3%), and 44.2% vs 12.9% high/very-high CV event risk (Framingham > or = 10%) (p<0.001). MS patients also had more psychopathology (PANSS) and greater severity (CGI).CONCLUSIONS: MS is highly prevalent in antipsychotic-treated patients and is associated with increased cardiovascular risk and psychopathology.

Balf, G., Stewart, T. D., Whitehead, R., et al. 2008. Metabolic adverse events in patients with mental illness treated with antipsychotics: A primary care

perspective. Primary Care Companion to the Journal of Clinical Psychiatry 10(1) 15-24.

Background: Individuals with mental illness are at a higher risk of medical mortality than the general population, primarily due to an increased risk of cardiovascular disease. There are a number of modifiable metabolic risk factors associated with some atypical antipsychotics that warrant careful monitoring and treatment in both psychiatric and primary care practice if the risk of cardiovascular disease is to be effectively reduced. Data Sources: Previous guidelines have focused on awareness of metabolic risk factors in psychiatry, yet few articles have appeared in the primary care-focused journals. We present pragmatic guidelines that focus on monitoring metabolic abnormalities in primary care based on established guidelines, including joint recommendations of the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity, and the Mount Sinai conference. Data Synthesis: All patients receiving atypical antipsychotic agents associated with metabolic adverse events should be routinely monitored for weight gain and abnormalities in blood glucose and lipid levels. Effective communication and collaboration between mental health and primary care services and better access to primary care screening and treatment for individuals with mental health problems are needed. Conclusion: There is a clear need for awareness among primary care physicians, particularly as metabolic effects of atypical antipsychotics such as blood pressure and glucose and lipid levels are possibly best monitored in a primary care setting. © Copyright 2008 Physicians Postgraduate Press, Inc.

Gold, K. J., Kilbourne, A. M. & Valenstein, M. 2008. Primary care of patients with serious mental illness: Your chance to make a difference. Journal of Family Practice 57(8) 515-525.

Miettola, J., Niskanen, L. K., Viinamaki, H., et al. 2008. Metabolic syndrome is associated with self-perceived depression. Scandinavian Journal of Primary Health Care 26(4) 203-210.

Objective. To study the association between metabolic syndrome (MetS) and self-perceived depression. Design. A cross-sectional community-based study. Setting. Semi-rural community of Lapinlahti in eastern Finland in 2005. Subjects. A total of 416 subjects in eight adult birth cohorts (55%) with complete Beck Depression Inventory (BDI-21) questionnaire data. Main outcome measures. The values of the 21 BDI items and the BDI-21 total score with a cut-off point of 14/15 were used to study the association between MetS and depression. National Cholesterol Education Programme (NCEP) 2005 criteria were used for MetS classification. Results. The total BDI-21 score was significantly higher in the subjects with MetS than in the subjects without MetS (p=0.020). Men with MetS were significantly worse off than men without MetS in the BDI-21 items of irritability (p=0.008), work inhibition (p=0.008), fatigability (p=0.037), weight loss (p=0.045), and loss of libido (p=0.014), while women were only so on the item of loss of libido

(p=0.007). In a logistic regression analysis using a BDI-21 cut-off point of 14/15 adjusted for age, marital status, vocational education, and working status, significant association was retained between perceived depression and elevated blood glucose among men (OR=1.697) and large waist circumference among women (OR=1.066). Conclusion. Elevated plasma glucose in men and central obesity in women are associated with self-perceived depression. This co-occurrence deserves attention in clinical practice. © 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS).

Rejas, J., Bobes, J., Arango, C., et al. 2008. Concordance of standard and modified NCEP ATP III criteria for identification of metabolic syndrome in outpatients with schizophrenia treated with antipsychotics: a corollary from the CLAMORS study. Schizophrenia Research 99(1-3) 23-8.

OBJECTIVE: To analyze the concordance between standard and modified NCEP-ATP-III criteria for identification of metabolic syndrome (MS) in outpatients with schizophrenia.METHOD: We used the sample from a cross-sectional study carried out to ascertain the prevalence of MS in schizophrenia. Kappa agreement and the symmetry Kendall's tau-b coefficients were calculated in a post-hoc analysis, a long with McNemar test and logistic regression models.RESULTS: The study enrolled 1,452 consecutive outpatients. MS was found in 24.6% (95%CI: 22.4%-26.8%) using the standard criteria and in 25.5% (23.2%-27.7%) using the modified criteria. Agreement was high; kappa 0.81 (p<0.0001) and tau-b 0.81 (p<0.0001), with a McNemar value of 0.2325. Kappa coefficients varied between 1.0 and 0.76 in subgroups according to sex, age-group, severity of disease, and duration of therapy.CONCLUSIONS: MS in outpatients with schizophrenia may be assessed by either the standard or the modified NCEP ATP III criteria without losing reliability.

Sicras-Mainar, A., Blanca-Tamayo, M., Rejas-Gutierrez, J., et al. 2008. Metabolic syndrome in outpatients receiving antipsychotic therapy in routine clinical practice: a cross-sectional assessment of a primary health care database. European Psychiatry: the Journal of the Association of European Psychiatrists 23(2) 100-8.

OBJECTIVE: To determine the prevalence of metabolic syndrome (MS) in outpatients treated with antipsychotics included in a primary-health-care database.METHODS: A cross-sectional study was carried out assessing an administrative outpatients claim-database from 5 primary-health-centers. Subjects on antipsychotics for more than 3 months were included. The control group was formed by the outpatients included in the database without exposition to any antipsychotic drugs. MS was defined according to the modified NCEP-ATP III criteria, and required confirmation of at least 3 of the 5 following components: body mass index >28.8 kg/m(2), triglycerides >150 mg/ml, HDL-cholesterol <40 mg/ml (men)/<50mg/ml (women), blood pressure >130/85 mmHg, and fasting serum glucose >110 mg/dl.RESULTS: We identified 742 patients [51.5% women, aged 55.1 (20.7) years] treated with first- or second-generation antipsychotics during 27.6 (20.3) months. Controls were 85.286 outpatients [50.5% women, aged 45.5 (17.7) years]. MS

prevalence was significantly higher in subjects on antipsychotics: 27.0% (95% CI, 23.8-30.1%) vs. 14.4% (14.1-14.6%); age- and sex-adjusted OR=1.38 (1.16-1.65, P<0.001). All MS components, except high blood pressure, were significantly more prevalent in the antipsychotic group, particularly body mass index >28.8 kg/m(2): 33.0% (29.6-36.4%) vs. 17.8% (17.6-18.1%), adjusted OR=1.63 (1.39-1.92, P<0.001), and low HDL-cholesterol levels: 48.4% (44.8-52.0%) vs. 29.3% (29.0-29.6%); adjusted OR=1.65 (1.42-1.93, P<0.001). Compared with the reference population, subjects with schizophrenia or bipolar disorder (BD), but not dementia, showed a higher prevalence of MS.CONCLUSIONS: Compared with the general outpatient population, the prevalence of MS was significantly higher in patients with schizophrenia or BD treated with antipsychotics.

Search question:What evidence is there to guide general practice about the treatment of obesity and overweight amongst adults with Serious Mental Illness.

Terms used:The complete search strategy is in the Appendix.

Limits applied:Age group Language Publication type Time limit

Adults English Any Last 10 years

Summary of resources searched and results:

Source No. of results*CINAHL 6Cochrane Library 2Embase 10Google 48Medline 16NICE Evidence Search 0TRIP database 3

TOTAL = 85

DisclaimerAlthough every effort has been made to ensure this information is accurate, it is possible it may not be representative of the whole body of evidence available. Both articles and internet resources may contain errors or out of date information. None of

the resources have been critically appraised. No responsibility can be accepted for any action taken on the basis of this information.

Results:

Grey literatureOptimizing care for people with serious mental illness and comorbid diabeteshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4497574/pdf/nihms701732.pdf

Obesity and serious mental illness: a critical reviewhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934464/

Serious mental illness and physical health problems: A discussion paperhttps://www.rcpsych.ac.uk/pdf/physical_health_paper-1%20copya.pdf

Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist reviewhttps://bmjopen.bmj.com/content/bmjopen/8/2/e019412.full.pdf

Identifying primary care quality indicators for people with serious mental illness: a systematic reviewhttps://bjgp.org/content/bjgp/67/661/e519.full.pdf

Improving the physical health of adults with severe mental illness: essential actionshttps://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/news/2016/physical-and-mental-health-report-25-oct-2016.pdf

A behavioral weight-loss intervention in person with serious mental illnesshttps://www.nejm.org/doi/pdf/10.1056/NEJMoa1214530

Obesity in patients with psychiatric conditionshttp://www.psychiatrictimes.com/special-reports/obesity-patients-psychiatric-conditions

Promoting awareness of physical health in people with a serious mental illness ‘a film for primary care teams’ Guidance Booklethttps://www.cambridgeshireandpeterboroughccg.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=15081

Obtaining full text: For help with getting the full text of these articles, please contact the PHE Knowledge & Library Services (libraries@phe.gov.uk)

Physical health checks in serious mental illness: A programme of research in secondary carehttps://ueaeprints.uea.ac.uk/56777/1/J_White_HSC_4393376_PhD_Thesis_FINAL_submitted_22-05-2015.pdf

Improving the physical health of adults with severe mental illness: essential actionshttps://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/news/2016/physical-and-mental-health-report-25-oct-2016.pdf

Improving physical health outcomes for patients with Serious Mental Illnesshttp://tvscn.nhs.uk/wp-content/uploads/2017/12/Sian-Robertts-Improving-physical-health-outcomes-for-SMI-patients-1.pdf

Severe mental illness (SMI) and physical health inequalities: briefinghttps://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing

Addressing Obesity and Inactivity in Females with Severe Mental Illness [SMI]shttp://austinpublishinggroup.com/community-medicine/fulltext/jcmhc-v2-id1009.php

Lifestyle interventions for obesity and overweight patients with severe mental illnesshttps://www.uptodate.com/contents/lifestyle-interventions-for-obesity-and-overweight-patients-with-severe-mental-illness

Health Promotion Programs for Persons with Serious Mental Illness: What Works?https://niatx.net/pdf/wicollaborative/HealthPromoSMI.pdf

‘Don't just Screen, Intervene’: What are the barriers and facilitators to weight loss for people with a serious mental illness and obesity? A systematic narrative metasynthesishttps://sapc.ac.uk/conference/2017/abstract/dont-just-screen-intervene-what-are-barriers-and-facilitators-weight-loss

GPs should promote physical activity in people with mental health issueshttps://www.guidelinesinpractice.co.uk/mental-health/gps-should-promote-physical-activity-in-people-with-mental-health-issues/453195.article

People with serious mental illnesses can lose weight, study showshttps://medicalxpress.com/news/2013-03-people-mental-illnesses-weight.html

Optimizing care for people with serious mental illness and comorbid diabeteshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4497574/pdf/nihms701732.pdf

Obesity and serious mental illness: a critical reviewhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934464/

Serious mental illness and physical health problems: A discussion paperhttps://www.rcpsych.ac.uk/pdf/physical_health_paper-1%20copya.pdf

Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist reviewhttps://bmjopen.bmj.com/content/bmjopen/8/2/e019412.full.pdf

Identifying primary care quality indicators for people with serious mental illness: a systematic reviewhttps://bjgp.org/content/bjgp/67/661/e519.full.pdf

Improving the physical health of adults with severe mental illness: essential actionshttps://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/news/2016/physical-and-mental-health-report-25-oct-2016.pdf

A behavioral weight-loss intervention in person with serious mental illnesshttps://www.nejm.org/doi/pdf/10.1056/NEJMoa1214530

Database searchAnonymous 2018. Interactive Obesity Treatment Approach (iOTA) for Obesity Prevention in Serious Mental Illness. Clinical Trials.

Aschbrenner, K. A., Naslund, J. A., Gorin, A. A., et al. 2018. Peer support and mobile health technology targeting obesity-related cardiovascular risk in young adults with serious mental illness: protocol for a randomized controlled trial. Contemporary clinical trials 74 97â106.��

Breslau, J., Leckman-Westin, E., Yu, H., et al. 2018. Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care. Administration and Policy in Mental Health and Mental Health Services Research 45(2) 276-285.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

Byrne, P. 2018. Physical health in psychiatric patients. Medicine 46(12) 725-730.Psychiatric patients have complex physical co-morbidities. They die on

average 17 years prematurely, and their final years are often blighted by poor physical health. Common physical diseases are described here, along with their pathogenesis and the multiple levels of interventions to prevent and treat them. The interventions that achieve the best results are already known; the challenge is using the best evidence in the right health setting to engage patients and professionals with consistency. Three key principles to follow are parity of esteem, âmake every ��contact countâ and âdon't just screen, interveneâ. Delirium is briefly discussed as an�� �� �� example of a medical condition presenting with apparent psychiatric symptoms but having medical causes and treatments. Other important life-threatening disorders are outlined, with suggested interventions â even for the late stages of illness.��

Gluth, A., White, D. & Ward, M. 2018. Chapter 20 - Lifestyle Interventions in Patients With Serious Mental Illness. In: Watson, R. R. & Zibadi, S. (eds.) Lifestyle in Heart Health and Disease. Academic Press.

Gron, A. O., Dalsgaard, E. M., Ribe, A. R., et al. 2018. Improving diabetes care among patients with severe mental illness: A systematic review of the effect of interventions. Primary Care Diabetes 12(4) 289-304.

Background and aim Individuals with severe mental illness (SMI) who suffer from type 2 diabetes (T2DM) are likely to be sub-optimally treated for their physical condition. This study aimed to review the effect of interventions in this population. Methods A systematic search in five databases was conducted in July 2017. Results Seven studies on multi-faced interventions were included. These comprised nutrition and exercise counselling, behavioural modelling and increased disease awareness aiming to reduce HbA1c, fasting plasma glucose, body mass index and weight. Conclusion Non-pharmacologic interventions in individuals with SMI and T2DM could possibly improve measures of diabetes care, although with limited clinical impact.

John, A., McGregor, J., Jones, I., et al. 2018. Premature mortality among people with severe mental illness â New evidence from linked primary care data�� . Schizophrenia Research 199 154-162.

Studies assessing premature mortality in people with severe mental illness (SMI) are usually based in one setting, hospital (secondary care inpatients and/or outpatients) or community (primary care). This may lead to ascertainment bias. This study aimed to estimate standardised mortality ratios (SMRs) for all-cause and cause-specific mortality in people with SMI drawn from linked primary and secondary care populations compared to the general population. SMRs were calculated using the indirect method for a United Kingdom population of almost four million between 2004 and 2013. The all-cause SMR was higher in the cohort identified from secondary care hospital admissions (SMR: 2.9; 95% CI: 2.8â3.0) than from primary ��care (SMR: 2.2; 95% CI: 2.1â2.3) when compared to the general population. The ��SMR for the combined cohort was 2.6 (95% CI: 2.5â2.6). Cause specific SMRs in ��the combined cohort were particularly elevated in those with SMI relative to the general population for ill-defined and unknown causes, suicide, substance abuse,

Parkinson's disease, accidents, dementia, infections and respiratory disorders (particularly pneumonia), and Alzheimer's disease. Solely hospital admission based studies, which have dominated the literature hitherto, somewhat over-estimate premature mortality in those with SMI. People with SMI are more likely to die by ill-defined and unknown causes, suicide and other less common and often under-reported causes. Comprehensive characterisation of mortality is important to inform policy and practice and to discriminate settings to allow for proportionate interventions to address this health injustice.

Lamontagne-Godwin, F., Burgess, C., Clement, S., et al. 2018. Interventions to increase access to or uptake of physical health screening in people with severe mental illness: A realist review. BMJ Open 8 (2) (no pagination)(e019412).

Objectives To identify and evaluate interventions aimed at increasing uptake of, or access to, physical health screening by adults with severe mental illness; to examine why interventions might work. Design Realist review. Setting Primary, secondary and tertiary care. Results A systematic search identified 1448 studies, of which 22 met the inclusion criteria. Studies were from Australia (n=3), Canada (n=1), Hong Kong (n=1), UK (n=11) and USA (n=6). The studies focused on breast cancer screening, infection preventive services and metabolic syndrome (MS) screening by targeting MS-related risk factors. The interventions could be divided into those focusing on (1) health service delivery changes (12 studies), using quality improvement, randomised controlled trial, cluster randomised feasibility trial, retrospective audit, cross-sectional study and satisfaction survey designs and (2) tests of tools designed to facilitate screening (10 studies) using consecutive case series, quality improvement, retrospective evaluation and pre-post audit study designs. All studies reported improved uptake of screening, or that patients had received screening they would not have had without the intervention. No estimation of overall effect size was possible due to heterogeneity in study design and quality. The following factors may contribute to intervention success: staff and stakeholder involvement in screening, staff flexibility when taking physical measurements (eg, using adapted equipment), strong links with primary care and having a pharmacist on the ward. Conclusions A range of interventions may be effective, but better quality research is needed to determine any effect size. Researchers should consider how interventions may work when designing and testing them in order to target better the specific needs of this population in the most appropriate setting. Behaviour-change interventions to reduce identified barriers of patient and health professional resistance to screening this population are required. Resource constraints, clarity over professional roles and better coordination with primary care need to be addressed. Copyright © 2018 Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved.

Osborn, D., Burton, A., Hunter, R., et al. 2018. Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: a cluster randomised controlled trial. The Lancet Psychiatry 5(2) 145-154.

Summary Background People with severe mental illnesses, including

psychosis, have an increased risk of cardiovascular disease. We aimed to evaluate the effects of a primary care intervention on decreasing total cholesterol concentrations and cardiovascular disease risk in people with severe mental illnesses. Methods We did this cluster randomised trial in general practices across England, with general practices as the cluster unit. We randomly assigned general practices (1:1) with 40 or more patients with severe mental illnesses using a computer-generated random sequence with a block size of four. Researchers were masked to allocation, but patients and general practice staff were not. We included participants aged 30â75 years with severe mental illnesses (schizophrenia, bipolar ��disorder, or psychosis), who had raised cholesterol concentrations (5·0 mmol/L) or a total:HDL cholesterol ratio of 4·0 mmol/L or more and one or more modifiable cardiovascular disease risk factors. Eligible participants were recruited within each practice before randomisation. The Primrose intervention consisted of appointments (â¤12) with a trained primary care professional involving manualised interventions for� cardiovascular disease prevention (ie, adhering to statins, improving diet or physical activity levels, reducing alcohol, or quitting smoking). Treatment as usual involved feedback of screening results only. The primary outcome was total cholesterol at 12 months and the primary economic analysis outcome was health-care costs. We used intention-to-treat analysis. The trial is registered with Current Controlled Trials, number ISRCTN13762819. Findings Between Dec 10, 2013, and Sept 30, 2015, we recruited general practices and between May 9, 2014, and Feb 10, 2016, we recruited participants and randomly assigned 76 general practices with 327 participants to the Primrose intervention (n=38 with 155 patients) or treatment as usual (n=38 with 172 patients). Total cholesterol concentration data were available at 12 months for 137 (88%) participants in the Primrose intervention group and 152 (88%) participants in the treatment-as-usual group. The mean total cholesterol concentration did not differ at 12 months between the two groups (5·4 mmol/L [SD 1·1] for Primrose vs 5·5 mmol/L [1·1] for treatment as usual; mean difference estimate 0·03, 95% CI â0·22 to 0·29; p=0·788). This result was unchanged by ��pre-agreed supportive analyses. Mean cholesterol decreased over 12 months (â0·22 mmol/L [1·1] for Primrose vs â0·36 mmol/L [1·1] for treatment as �� ��usual). Total health-care costs (£1286 [SE 178] in the Primrose intervention group vs £2182 [328] in the treatment-as-usual group; mean difference â£895, 95% CI ��â1631 to â160; p=0·012) and psychiatric inpatient costs (£157 [135] vs £956 �� ��[313]; â£799, â1480 to â117; p=0·018) were lower in the Primrose intervention �� �� ��group than the treatment-as-usual group. Six serious adverse events of hospital admission and one death occurred in the Primrose group (n=7) and 23, including three deaths, occurred in the treatment-as-usual group (n=18). Interpretation Total cholesterol concentration at 12 months did not differ between the Primrose and treatment-as-usual groups, possibly because of the cluster design, good care in the treatment-as-usual group, short duration of the intervention, or suboptimal focus on statin prescribing. The association between the Primrose intervention and fewer psychiatric admissions, with potential cost-effectiveness, might be important. Funding National Institute of Health Research Programme Grants for Applied Research.

Osborn, D. P., Petersen, I., Beckley, N., et al. 2018. Weight change over two years in people prescribed olanzapine, quetiapine and risperidone in UK primary care: Cohort study in THIN, a UK primary care database. Journal of Psychopharmacology 32(10) 1098-1103.

Background:Follow-up studies of weight gain related to antipsychotic treatment beyond a year are limited in number. We compared weight change in the three most commonly prescribed antipsychotics in a representative UK General Practice database.Method:We conducted a cohort study in United Kingdom primary care records of people newly prescribed olanzapine, quetiapine or risperidone. The primary outcome was weight in each six month period for two years after treatment initiation. Weight changes were compared using linear regression, adjusted for age, baseline weight and diagnosis.Results:N = 6338 people received olanzapine, 12,984 quetiapine and 6556 risperidone. Baseline weight was lowest for men treated with olanzapine (80.8 kg versus 83.5 kg quetiapine, 82.0 kg risperidone) and women treated with olanzapine (67.7 kg versus 71.5 kg quetiapine 68.4 kg risperidone. Weight gain occurred during treatment with all three drugs. Compared with risperidone mean weight gain was higher with olanzapine (adjusted co-efficient +1.24 kg (95% confidence interval: 0.69–1.79 kg per six months) for men and +0.77 kg (95% confidence interval: 0.29–1.24 kg) for women). Weight gain with quetiapine was lower in unadjusted models compared with risperidone, but this difference was not significant after adjustment.Conclusion:Olanzapine is more commonly prescribed to people with lower weight. However, after accounting for baseline weight, age, sex and diagnosis, olanzapine is still associated with greater weight gain over two years than risperidone or quetiapine. Baseline weight does not ameliorate the risks of weight gain associated with antipsychotic medication. Weight gain should be assertively discussed and managed for people prescribed antipsychotics, especially olanzapine.

Perrin, J., Reimann, B., Capobianco, J., et al. 2018. A Model of Enhanced Primary Care for Patients with Severe Mental Illness. North Carolina Medical Journal 79(4) 240-244.

Life expectancy and other outcomes for patients with serious mental illness (SMI) are unacceptably poor, largely due to a high prevalence of poorly controlled chronic diseases, high rates of tobacco use, and low rates of preventive care services. Since many of these illnesses are effectively treated in primary care settings, integrating primary care with behavioral health care is necessary to narrow health disparities for patients with SMI.

Walls, M., Broder-Fingert, S., Feinberg, E., et al. 2018. Prevention and Management of Obesity in Children with Autism Spectrum Disorder Among Primary Care Pediatricians. Journal of Autism & Developmental Disorders 48(7) 2408-2417.

Children with autism spectrum disorder (ASD) are at high risk for being overweight and obese. Little is known about how obesity in children with ASD is being addressed in primary care. This article reports findings from a survey completed by 327 general pediatricians, which included a fictional clinical vignette

and Likert-scales assessing attitudes, practices, self-efficacy, and barriers to obesity management. Although the majority of respondents agreed pediatricians should be the main providers to manage obesity in children with ASD, few reported receiving adequate training to do so. Pediatricians were more likely to refer to developmental-behavioral pediatricians and dietitians for a child with ASD compared to a child without ASD. Higher self-efficacy was associated with increased weight-related counseling frequency by pediatricians.

Young, A. S., Cohen, A. N., Chang, E. T., et al. 2018. A clustered controlled trial of the implementation and effectiveness of a medical home to improve health care of people with serious mental illness: study protocol. BMC Health Services Research 18(1) 428.

People with serious mental illness (SMI) die many years prematurely, with rates of premature mortality two to three times greater than the general population. Most premature deaths are due to “natural causes,” especially cardiovascular disease and cancer. Often, people with SMI are not well engaged in primary care treatment and do not receive high-value preventative and medical services. There have been numerous efforts to improve this care, and few controlled trials, with inconsistent results. While people with SMI often do poorly with usual primary care arrangements, research suggests that integrated care and medical care management may improve treatment and outcomes, and reduce treatment costs.

Annamalai, A., Kosir, U. & Tek, C. 2017. Prevalence of obesity and diabetes in patients with schizophrenia. World journal of diabetes 8(8) 390-396.

AIM: To compare the prevalence of diabetes in patients with schizophrenia treated at a community mental health center with controls in the same metropolitan area and to examine the effect of antipsychotic exposure on diabetes prevalence in schizophrenia patients. METHODS: The study was a comprehensive chart review of psychiatric notes of patients with schizophrenia and schizoaffective disorder treated at a psychosis program in a community mental health center. Data collected included psychiatric diagnoses, diabetes mellitus diagnosis, medications, allergies, primary care status, height, weight, body mass index (BMI), substance use and mental status exam. Local population data was downloaded from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Statistical methods used were Ï(2) test, �Student's t test, general linear model procedure and binary logistic regression analysis. RESULTS: The study sample included 326 patients with schizophrenia and 1899 subjects in the population control group. Demographic data showed control group was on average 7.6 years older (P = 0.000), more Caucasians (78.7% vs 38.3%, P = 0.000), and lower percentage of males (40.7% vs 58.3%, P = 0.000). Patients with schizophrenia had a higher average BMI than the subjects in the population control (32.11, SD = 7.72 vs 27.62, SD = 5.93, P = 0.000). Patients with schizophrenia had a significantly higher percentage of obesity (58.5% vs 27%, P = 0.000) than the population group. The patients with schizophrenia also had a much higher rate of diabetes compared to population control (23.9% vs 12.2%, P = 0.000). After controlling for age sex, and race, having schizophrenia was still associated with increased risk for both obesity (OR = 3.25, P = 0.000) and diabetes (OR = 2.42, P =

0.000). The increased risk for diabetes remained even after controlling for obesity (OR = 1.82, P = 0.001). There was no difference in the distribution of antipsychotic dosage, second generation antipsychotic use or multiple antipsychotic use within different BMI categories or with diabetes status in the schizophrenia group. CONCLUSION: This study demonstrates the high prevalence of obesity and diabetes in schizophrenia patients and indicates that antipsychotics may not be the only contributor to this risk.

Black, D. R. & Held, M. L. 2017. Cardiovascular risk screening for individuals with serious mental illness. Social Work in Health Care 56(9) 809-821.

Cardiovascular disease (CVD) is a significant health risk for individuals with serious mental illness (SMI). Screening for CVD risk factors is a key strategy to reduce this health disparity. This study examined medical, lifestyle, and access predictors for comprehensive screening. Data on 1036 adults were analyzed from the 2015 National Health Interview Survey. Multivariate multinomial logistic regression was used to examine factors associated with individuals with SMI receiving CVD risk screening in the past 12 months. The presence of a metabolic disorder (diabetes or high cholesterol), increased age, increased outpatient visits, and seeing a primary care provider, either alone or in conjunction with a specialty care provider, were significantly associated with receiving all screening measures. Increasing provider awareness of additional CVD risk factors is an essential step to improving early detection of health risks for individuals with SMI. Integrated health settings that combine traditional primary care and mental health services may reduce the health disparity for this population by increasing odds of early detection and ongoing monitoring for high-risk populations.

Blackburn, R., Osborn, D., Walters, K., et al. 2017. Statin prescribing for people with severe mental illnesses: a staggered cohort study of 'real-world' impacts. BMJ Open 7(3) e013154.

OBJECTIVES: To estimate the 'real-world effectiveness of statins for primary prevention of cardiovascular disease (CVD) and for lipid modification in people with severe mental illnesses (SMI), including schizophrenia and bipolar disorder.DESIGN: Series of staggered cohorts. We estimated the effect of statin prescribing on CVD outcomes using a multivariable Poisson regression model or linear regression for cholesterol outcomes.SETTING: 587 general practice (GP) surgeries across the UK reporting data to The Health Improvement Network.PARTICIPANTS: All permanently registered GP patients aged 40-84 years between 2002 and 2012 who had a diagnosis of SMI. Exclusion criteria were pre-existing CVD, statin-contraindicating conditions or a statin prescription within the 24 months prior to the study start.EXPOSURE: One or more statin prescriptions during a 24-month 'baseline' period (vs no statin prescription during the same period).MAIN OUTCOME MEASURES: The primary outcome was combined first myocardial infarction and stroke. All-cause mortality and total cholesterol concentration were secondary outcomes.

RESULTS: We identified 2944 statin users and 42 886 statin non-users across the staggered cohorts. Statin prescribing was not associated with significant reduction in CVD events (incident rate ratio 0.89; 95% CI 0.68 to 1.15) or all-cause mortality (0.89; 95% CI 0.78 to 1.02). Statin prescribing was, however, associated with statistically significant reductions in total cholesterol of 1.2 mmol/L (95% CI 1.1 to 1.3) for up to 2 years after adjusting for differences in baseline characteristics. On average, total cholesterol decreased from 6.3 to 4.6 in statin users and 5.4 to 5.3 mmol/L in non-users.CONCLUSIONS: We found that statin prescribing to people with SMI in UK primary care was effective for lipid modification but not CVD events. The latter finding may reflect insufficient power to detect a smaller effect size than that observed in randomised controlled trials of statins in people without SMI.

Blane, D. N., Mackay, D., Guthrie, B., et al. 2017. Smoking cessation interventions for patients with coronary heart disease and comorbidities: an observational cross-sectional study in primary care. British Journal of General Practice 67(655) e118-e129.

BACKGROUND: Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities.AIM: To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD.DESIGN AND SETTING: Cross-sectional study of 81 456 adults with CHD in primary care in Scotland.METHOD: Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed.RESULTS: The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small.CONCLUSION: Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support.

Bourassa, K. A., McKibbin, C. L., Hartung, C. M., et al. 2017. Barriers and facilitators of obesity management in families of youth with emotional and

behavioral disorders. Journal of Health Psychology 22(11) 1469-1479.While youth with emotional and behavioral disorders experience increased

rates of obesity, few obesity interventions exist that are tailored to their needs. Qualitative methods were employed to elucidate obesity management practices in this population. In all, 56 participants (i.e. 21 youths with emotional and behavioral disorders, 20 caregivers of youth with emotional and behavioral disorders, and 15 mental health providers) were recruited from community mental health centers. Participants completed a demographic form and semi-structured interview regarding obesity-related behaviors. Barriers (e.g. psychiatric symptoms) and facilitators (e.g. social support) to obesity management were identified. These results highlight preferred intervention components for this unique population.

de Hert, M. & Detraux, J. 2017. Reversing the downward spiral for people with severe mental illness through educational innovations. World Psychiatry 16(1) 41-42.

John, A. N., Karen, L. W., Gregory, J. M., et al. 2017. Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis. General hospital psychiatry 47 83.

To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness.We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups.Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (ââ°Â¤6-months or Ã�¢â°Â¥12-months). Lifestyle interventions of ââ°Â¤6-months duration showed � �greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ââ°Â¥12-months �duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%).Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ââ°Â¥12-months duration compared to Ã�¢â°Â¤6-months duration appear to achieve more consistent outcomes, though effect �sizes are similar for both shorter and longer duration interventions.Copyright é �2017. Published by Elsevier Inc.

Kronenberg, C., Doran, T., Goddard, M., et al. 2017. Identifying primary care quality indicators for people with serious mental illness: A systematic review. British Journal of General Practice 67(661) e519-e530.

Background Serious mental illness (SMI) - which comprises long-Term conditions such as schizophrenia, bipolar disorder, and other psychoses - has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. Aim The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care. Design and setting A systematic literature review, combined with a search of quality indicator databases and guidelines. Method The authors assessed whether indicators could be measured from routine data and the quality of the evidence. Results Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. Conclusion With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes. Copyright © British Journal of General Practice.

Olsen, C. G., Boltri, J. M., Amerine, J., et al. 2017. Lacking a Primary Care Physician Is Associated With Increased Suffering in Patients With Severe Mental Illness. The Journal of Primary Prevention 38(6) 583-596.

We evaluated the relationship between lack of a primary care physician (PCP) and patients with severe mental illness (SMI), who have poorer health and experience more suffering. Using a blinded retrospective record review of 137 patients with SMI, divided between inpatients (n = 70) and outpatients (n = 67), we compared the two groups to determine if lack of a PCP is associated with increased suffering and worse overall health. We included history of preventive services, having a PCP, and comorbid conditions. Multiple linear regressions determined the relationship between lacking a PCP and lifestyle problems, lack of preventive care, and Burden of Suffering. We found that in SMI patients, lack of a PCP is associated with increased lifestyle problems, lacking preventive care, increased Burden of Suffering and cervical dysplasia. Health policy changes are needed to improve outcomes for patients with SMI by increasing access to PCPs and preventive services.

Strong, J. R., Lemaire, G. S. & Murphy, L. S. 2017. Assessment of a Chronic Disease Self-Management Program to Increase Physical Activity of Adults With Severe Mental Illness. Archives of Psychiatric Nursing 31(1) 137-140.

Individuals with severe mental illness (SMI) experience excessive co-morbidities and early mortality. Self-management programs have the potential to increase physical activity levels of individuals with SMI and reduce the incidence of co-morbidities. The purpose of this quality improvement project was to assess a

chronic disease self-management program (CDSMP) to increase physical activity of adults with SMI measured by daily steps tracked with a pedometer. Results of data analysis indicated no statistically significant difference in steps across the six-week program. However, findings suggested that individuals with SMI are capable of using a pedometer and tracking steps on a daily basis.

Mangurian, C., Newcomer, J. W., Modlin, C., et al. 2016. Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review. Journal of General Internal Medicine 31(9) 1083-1091.

Close to 19 million US adults have severe mental illnesses (SMI), and they die, on average, 25 years earlier than the general population, most often from cardiovascular disease (CVD). Many of the antipsychotic medications used to treat SMI contribute to CVD risk by increasing risk for obesity, type 2 diabetes, dyslipidemia, and hypertension. Based on compelling evidence, the American Diabetes Association and the American Psychiatric Association developed guidelines for metabolic screening and monitoring during use of these medications.

Naslund, J. A., Aschbrenner, K. A., Scherer, E. A., et al. 2016. Lifestyle Intervention for People with Severe Obesity and Serious Mental Illness. American Journal of Preventive Medicine 50(2) 145-153.

Introduction People with serious mental illness experience elevated severe obesity rates, yet limited evidence documents whether lifestyle intervention participation can benefit these individuals. This study examined the impact of the In SHAPE lifestyle intervention on weight loss among participants with serious mental illness and severe obesity (BMI >=40) compared with participants who are overweight (BMI 25 to <30) and have class I (BMI 30 to <35) or class II (BMI 35 to <40) obesity. Methods Data were combined from three trials of the 12-month In SHAPE intervention for individuals with serious mental illness collected between 2007 and 2013 and analyzed in 2014. In SHAPE includes individual weekly meetings with a fitness trainer, a gym membership, and nutrition education. The primary outcome was weight loss. Secondary outcomes were fitness, blood pressure, lipids, and program adherence. Results Participants (N=192) were diagnosed with schizophrenia spectrum (53.1%) or mood (46.9%) disorders. At 12 months, the overall sample showed significant weight loss, but differences among BMI groups were not significant (severe obesity, 2.57% [7.98%]; class II, 2.26% [8.69%]; class I, 1.05% [6.86%]; overweight, 0.83% [7.62%]). One third of participants with severe obesity achieved >=5% weight loss, which was comparable across groups. More participants with severe obesity achieved >=10% weight loss (20%) than overweight (2.9%, p=0.001) and class I (5.9%, p<0.001), but not class II (17.8%, p=0.974), obesity groups. Conclusions People with severe obesity and serious mental illness benefit similarly to those in lower BMI groups from lifestyle intervention participation. Copyright © 2016 American Journal of Preventive Medicine.

Osborn, D., Burton, A., Walters, K., et al. 2016. Evaluating the clinical and cost effectiveness of a behaviour change intervention for lowering cardiovascular disease risk for people with severe mental illnesses in primary care

(PRIMROSE study): study protocol for a cluster randomised controlled trial. Trials 17(1) 80.

People with severe mental illnesses die up to 20 years earlier than the general population, with cardiovascular disease being the leading cause of death. National guidelines recommend that the physical care of people with severe mental illnesses should be the responsibility of primary care; however, little is known about effective interventions to lower cardiovascular disease risk in this population and setting. Following extensive peer review, funding was secured from the United Kingdom National Institute for Health Research (NIHR) to deliver the proposed study. The aim of the trial is to test the effectiveness of a behavioural intervention to lower cardiovascular disease risk in people with severe mental illnesses in United Kingdom General Practices.

Vazin, R., McGinty, E. E., Dickerson, F., et al. 2016. Perceptions of strategies for successful weight loss in persons with serious mental illness participating in a behavioral weight loss intervention: A qualitative study. Psychiatric rehabilitation journal 39(2) 137-146.

OBJECTIVE: The purpose of this study was to describe perceptions of weight loss strategies, benefits, and barriers among persons with serious mental illness who lost weight in the ACHIEVE behavioral weight loss intervention. METHODS: Semistructured interviews with 20 ACHIEVE participants were conducted and analyzed using an inductive coding approach. RESULTS: Participants perceived tailored exercise sessions, social support, and dietary strategies taught in ACHIEVE-such as reducing portion sizes and avoiding sugar-sweetened beverages-as useful weight loss strategies. Health benefits, improved physical appearance, self-efficacy, and enhanced ability to perform activities of daily living were commonly cited benefits of intervention participation and weight loss. Some participants reported challenges with giving up snack food and reducing portion sizes, and barriers to exercise related to medical conditions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: There is emerging evidence that behavioral weight loss interventions can lead to clinically meaningful reductions in body weight among persons with serious mental illness. The perspective of persons with serious mental illness regarding strategies for, benefits of, and barriers to weight loss during participation in behavioral weight loss programs provide insight into which elements of multicomponent interventions such as ACHIEVE are most effective. The results of this study suggest that tailored exercise programs, social support, and emphasis on nonclinical benefits of intervention participation, such as improvements in self-efficacy and the ability to participate more actively in family and community activities, are promising facilitators of engagement and success in behavioral weight loss interventions for the population with serious mental illness. (PsycINFO Database Record Copyright (c) 2016 APA, all rights reserved).

Anonymous 2015. Primary prevention of overweight/obesity in adult populations. PROSPERO.

Annamalai, A. & Tek, C. 2015. An Overview of Diabetes Management in Schizophrenia Patients: Office Based Strategies for Primary Care Practitioners and Endocrinologists. International Journal of Endocrinology 2015 8.

Bartels, S. J., Pratt, S. I., Aschbrenner, K. A., et al. 2015. Pragmatic replication trial of health promotion coaching for obesity in serious mental illness and maintenance of outcomes. American journal of psychiatry 172(4) 344â352.��

Chwastiak, L. A., Freudenreich, O., Tek, C., et al. 2015. Clinical management of comorbid diabetes and psychotic disorders. The Lancet. Psychiatry 2(5) 465-476.

Individuals with psychotic disorders experience substantial health disparities with respect to diabetes, including increased risk of incident diabetes and of poor diabetes outcomes (eg, diabetes complications and mortality). Low-quality medical care for diabetes is a significant contributor to these poor health outcomes. A thoughtful approach to both diabetes pharmacotherapy and drug management for psychotic disorders is essential, irrespective of whether treatment is given by a psychiatrist, a primary care provider, or an endocrinologist. Exposure to drugs with high metabolic liability should be minimised, and both psychiatric providers and medical providers need to monitor patients to ensure that medical care for diabetes is adequate. Promising models of care management and team approaches to coordination and integration of care highlight the crucial need for communication and cooperation among medical and psychiatric providers to improve outcomes in these patients. Evidence-based programmes that promote weight loss or smoking cessation need to be more accessible for these patients, and should be available in all the settings where they access care.

Ferrara, M., Mungai, F., Miselli, M., et al. 2015. Strategies to implement physical health monitoring in people affected by severe mental Illness: A literature review and introduction to the Italian adaptation of the positive cardiometabolic health algorithm. Journal of Psychopathology 21(3) 269-280.

Objectives To review the strategies implemented in clinical practice to increase monitoring and active interventions to reduce cardiovascular risk in individuals with severe mental illness and their possible implementation in first episode psychosis (FEP) care. Methods A PubMed literature search was performed using the following key words: "metabolic syndrome", "antipsychotic", "schizophrenia", "psychosis", "severe mental illness", "intervention", "obesity", "weight", "physical health" and a combination of all above. Additional papers were identified through references and based on expert consultation as necessary. Results The review identified 14 studies in which a variety of different monitoring instruments were adopted in a range of clinical settings. Only three studies were carried out in subjects affected by FEP. The degree to which systematic monitoring was successfully utilised varied across studies and was mediated by a broad range of barriers. Nevertheless, some studies showed that the introduction of a systematic

approach can improve the monitoring by up to 100%. Conclusions Despite heightened risk of developing cardiovascular and metabolic disorders, systematic monitoring of physical health is often suboptimal and haphazard. There is a paucity of specific protocols for people with FEP. Results seem more promising when the approach to physical health is multidisciplinary and integrated with primary care. In this regard, a computerized version of the Australian Positive Cardiometabolic Health Algorithm, along with a health check list completed by psychiatric nurses, seems to be the basis to improve monitoring and effective interventions aimed at preventing cardiovascular events in individuals suffering from FEP.

Iyer, S. P. & Young, A. S. 2015. Health screening, counseling, and hypertension control for people with serious mental illness at primary care visits. General Hospital Psychiatry 37(1) 60-66.

Objective This study sought to determine if primary care visits for people with serious mental illness (SMI) demonstrate different rates of basic physical health services compared to others, and to determine factors associated with differing rates of these measures in people with SMI. Method The study used 2005â2010 visit-level�� primary care data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The provision of health counseling, receipt of any diagnostic or screening test, measurement of blood pressure or weight and evidence of hypertension control were assessed, adjusting for identified patient, provider and visit-level factors. Results After adjustment for covariates, we found no significant differences between visits for people with SMI and those without for any outcome. Probability of blood pressure measurement and diagnostic or screening testing significantly increased over time. Conclusion The lack of significant differences found here might be due to adjustment for covariates, a focus only on primary care visits, the use of visit-level data or evolution over time. Mortality differences for people with SMI may be attributable to those not receiving primary care, self-management of disease or subsets of the population requiring targeted interventions.

Mangurian, C., Newcomer, J. W., Vittinghoff, E., et al. 2015. Diabetes screening among underserved adults with severe mental illness who take antipsychotic medications. JAMA Internal Medicine 175(12) 1977-1979.

Adults in the United States with severe mental illness (SMI), such as schizophrenia and bipolar disorder (totaling approximately 7 million), are estimated to die, on average, 25 years earlier than the general population, largely of premature cardiovascular disease.1 The Institute of Medicine2 has called for improvements in health care for this population. Severe mental illness is associated with elevated risk for type 2 diabetes mellitus.3 Treatment with antipsychotic medications contributes to risk, with most evidence focused on second-generation antipsychotic medications, but similar increases in risk are reported with older and newer medications.4 The American Diabetes Association5 recommends annual diabetes screening for patients treated with antipsychotic medications, and public health administrators have targeted this population for improved health screening.6 To our knowledge, no studies have examined screening rates in this highest-risk population of adults with

SMI because of limitations in public health medical records. We examined diabetes screening among publicly insured adults with SMI taking antipsychotic medications using matched administrative data for physical and mental health care services in a large health care system. We measured diabetes screening prevalence among patients with SMI treated with antipsychotic medications and assessed characteristics predictive of screening.

McCarron, R. M. 2015. Integrated Care at the Interface of Psychiatry and Primary Care: Prevention of Cardiovascular Disease. Psychiatric Clinics of North America 38(3) 463-74.

Patients with mental illness, particularly serious mental illness, are more likely to suffer from common disorders without optimal treatment. Changes in preventive practice patterns cannot be fully realized on a large scale until clinicians are trained how to routinely provide this care. Psychiatrists may consider using preventive care strategies in the area of cardiovascular health, as cardiovascular disease is the most common cause of death and disproportionately affects patients with mental illness. At minimum, psychiatrists are well positioned to work collaboratively with primary care providers to address psychopathology that may interfere with adherence to the treatment plan.

Rao, S., Raney, L. & Xiong, G. L. 2015. Reducing medical comorbidity and mortality in severe mental illness: collaboration with primary and preventive care could improve outcomes. Current Psychiatry 14 14+.

Reilly, S., Olier, I., Planner, C., et al. 2015. Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK. BMJ Open 5(12) e009010.

Objectives Little is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English region and deprivation quintile, antipsychotic and antidepressant medication prescription rates for people with SMI, and prevalence rates of common comorbidities in people with SMI compared with people without SMI.Design Retrospective cohort study from 2000 to 2012.Setting 627 general practices contributing to the Clinical Practice Research Datalink, a UK primary care database.Participants Each identified case (346 551) was matched for age, sex and general practice with 5 randomly selected control cases (1 732 755) with no diagnosis of SMI in each yearly time point.Outcome measures Prevalence rates were calculated for 16 conditions.Results SMI rates were highest in Scotland and in more deprived areas. Rates increased in England, Wales and Northern Ireland over time, with the largest increase in Northern Ireland (0.48% in 2000/2001 to 0.69% in 2011/2012). Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI. The discrepancy between the prevalence of those with and without SMI increased over time for most conditions. A greater increase in the mean number of additional conditions was observed in the SMI population over the study period (0.6 in 2000/2001 to 1.0 in 2011/2012) compared with those without

SMI (0.5 in 2000/2001 to 0.6 in 2011/2012). For both groups, most conditions were more prevalent in more deprived areas, whereas for the SMI group conditions such as hypothyroidism, chronic kidney disease and cancer were more prevalent in more affluent areas.Conclusions Our findings highlight the health inequalities faced by people with SMI. The provision of appropriate timely health prevention, promotion and monitoring activities to reduce these health inequalities are needed, especially in deprived areas.

Speyer, H., Norgaard, H. C., Hjorthoj, C., et al. 2015. Protocol for CHANGE: a randomized clinical trial assessing lifestyle coaching plus care coordination versus care coordination alone versus treatment as usual to reduce risks of cardiovascular disease in adults with schizophrenia and abdominal obesity. BMC Psychiatry 15 119.

BACKGROUND: Life expectancy in patients with schizophrenia is reduced by 20 years for males and 15 years for females compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being the single largest cause of death.METHODS/DESIGN: The CHANGE trial is an investigator-initiated, independently funded, randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment. 450 patients aged 18 years or above, diagnosed with schizophrenia spectrum disorders and increased waist circumference, will be recruited and randomized 1:1:1 to 12-months interventions. We will compare the effects of 1) affiliation to the CHANGE team, offering a tailored, manual-based intervention targeting physical inactivity, unhealthy dietary habits, and smoking, and facilitating contact to their general practitioner to secure medical treatment of somatic comorbidity; versus 2) affiliation to a care coordinator who will secure guideline-concordant monitoring and treatment of somatic comorbidity by facilitating contact to their general practitioner; versus 3) treatment as usual to evaluate the potential add-on effects of lifestyle coaching plus care coordination or care coordination alone to treatment as usual. The primary outcome is the 10-year risks of cardiovascular disease assessed at 12 months after randomization.DISCUSSION: The premature mortality observed in this vulnerable population has not formerly been addressed specifically by using composite surrogate outcomes for mortality. The CHANGE trial expands the evidence for interventions aiming to reduce the burden of metabolic disturbances with a view to increase life expectancy. Here, we present the trial design, describe the methodological concepts in detail, and discuss the rationale and challenges of the intermediate outcomes.TRIAL REGISTRATION: Clinical Trials.gov NCT01585493 . Date of registration 27(th) of March 2012.

Aschbrenner, K. A., Pepin, R., Mueser, K. T., et al. 2014. A mixed methods exploration of family involvement in medical care for older adults with serious mental illness. International Journal of Psychiatry in Medicine 48(2) 121-33.

OBJECTIVE: Many older persons with serious mental illness (SMI) suffer from high rates of comorbid medical conditions. Although families play a critical role in psychiatric illness management among adults with SMI, their contributions to

improving health outcomes in this population has received little attention. This study explored family involvement in medical care for older adults with SMI.METHODS: This mixed methods study involved analysis of quantitative data collected from older adults with SMI and cardiovascular risk (n = 28) participating in a pilot study of an intervention designed to improve patient-centered primary care augmented by qualitative interviews with their relatives (n = 13) to explore family involvement in medical care.RESULTS: Approximately 89% of older adults with SMI reported family involvement in at least one aspect of their medical care (e.g., medication reminders, medical decision making). However, many family members reported that they were rarely involved in their relative's medical visits, and most did not perceive a need to be involved during routine care. Family members identified obesity as their relative's primary health concern and many wanted guidance from providers on effective strategies for supporting weight loss.CONCLUSIONS: Although many family members did not perceive a need to be involved in their relative's routine medical visits, they expressed interest in talking with providers about how to help their relative change unhealthy behaviors. Educating patients, families, and providers about the potential benefits of family involvement in medical care, including routine medical visits for persons with SMI and cardiovascular health risk may promote patient- and family-centered collaboration in this high-risk population.

Bradshaw, T. & Mairs, H. 2014. Obesity and Serious Mental Ill Health: A Critical Review of the Literature. Healthcare 2(2) 166-82.

Individuals who experience serious mental ill health such as schizophrenia are more likely to be overweight or obese than others in the general population. This high prevalence of obesity and other associated metabolic disturbances, such as type 2 diabetes and cardiovascular disease, contribute to a reduced life expectancy of up to 25 years. Several reasons have been proposed for high levels of obesity including a shared biological vulnerability between serious mental ill health and abnormal metabolic processes, potentially compounded by unhealthy lifestyles. However, emerging evidence suggests that the most significant cause of weight gain is the metabolic side effects of antipsychotic medication, usual treatment for people with serious mental ill health. In this paper we review the prevalence of obesity in people with serious mental ill health, explore the contribution that antipsychotic medication may make to weight gain and discuss the implications of this data for future research and the practice of mental health and other professionals.

Happell, B., Stanton, R., Hoey, W., et al. 2014. Cardiometabolic Health Nursing to Improve Health and Primary Care Access in Community Mental Health Consumers: Baseline Physical Health Outcomes from a Randomised Controlled Trial. Issues in Mental Health Nursing 35(2) 114-121.

People with serious mental illness (SMI) are more likely to have poorer health and poorer health behaviours, and therefore are at greater risk for cardiometabolic health comorbidities compared to those without SMI. Referral to a specialist cardiometabolic health care nurse may result in increased detection of poor

cardiometabolic health in at-risk individuals. In this article, we present the results of the physical health measures of people with serious mental illness who have accessed a community mental health service in a regional centre and argue for the need for a multidisciplinary approach. Our data show the high prevalence of obesity, hypertension, low activity, smoking and nicotine dependence, alcohol misuse disorders, and poor diet among people with serious mental illness. The high prevalence of at-risk factors for poor cardiometabolic health in people with serious mental illness adds support for the role of a specialist cardiometabolic health care nurse in the detection and referral for multidisciplinary treatment to improve the physical health outcomes for people with serious mental illness.

Searle, A., Haase, A. M., Chalder, M., et al. 2014. Participantsâ experiences of ��facilitated physical activity for the management of depression in primary care. Journal of Health Psychology 19(11) 1430-1442.

Sinclair, A. J., Hillson, R., Bayer, A. J., et al. 2014. Diabetes and dementia in older people: a Best Clinical Practice Statement by a multidisciplinary National Expert Working Group. Diabetic Medicine 31(9) 1024-31.

Both dementia and diabetes mellitus are long-term disabling conditions and each may be a co-morbidity of the other. Type 2 diabetes is associated with a 1.5- to 2-fold higher risk of dementia. Diabetes also may occur for the first time in many individuals with mental ill health, including cognitive impairment and dementia, and this may complicate management and lead to difficulties in self-care. Case finding is often poor for cognitive impairment in medical settings and for diabetes in mental health settings and this needs to be addressed in the development of care pathways for both conditions. Many other deficiencies in quality care (both for dementia and diabetes) currently exist, but we hope that this Best Clinical Practice Statement will provide a platform for further work in this area. We have outlined the key steps in an integrated care pathway for both elements of this clinical relationship, produced guidance on identifying each condition, dealt with the potentially hazardous issue of hypoglycaemia, and have outlined important competencies required of healthcare workers in both medical/diabetes and mental health settings to enhance clinical care.

Ackerman, J. R. 2013. Weight loss in persons with serious mental illness. New England Journal of Medicine 369(5) 486.

Daumit, G. L., Dickerson, F. B. & Appel, L. J. 2013. Weight loss in persons with serious mental illness. The New England journal of medicine 369(5) 486-487.

Daumit, G. L., Dickerson, F. B., Wang, N. Y., et al. 2013. A behavioral weight-loss intervention in persons with serious mental illness. New England Journal of Medicine 368(17) 1594-602.

BACKGROUND: Overweight and obesity are epidemic among persons with

serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.METHODS: We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.RESULTS: Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was -3.2 kg (-7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events.CONCLUSIONS: A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.).

Pagoto, S., Lemon, S. & Whiteley, J. 2013. Weight loss in persons with serious mental illness. New England Journal of Medicine 369(5) 485-486.

Patel, A., Keogh, J. W. L., Kolt, G. S., et al. 2013. The long-term effects of a primary care physical activity intervention on mental health in low-active, community-dwelling older adults. Aging & Mental Health 17(6) 766-772.

Objectives:To examine the effect that physical activity delivered via two different versions of the Green Prescription (a primary care physical activity scripting program) had on depressive symptomatology and general mental health functioning over a 12-month period in non-depressed, low-active, community-dwelling older adults. Method:Two hundred and twenty-five participants from the Healthy Steps study took part in the present study. Healthy Steps participants were randomized to receive either the standard time-based or a modified pedometer-based Green Prescription. Depression, mental health functioning and physical activity were measured at baseline, post-intervention (3 months post-baseline) and at the 9-month

follow-up period. Results:At post-intervention, a positive association was found between increases in leisure-time physical activity and total walking physical activity and a decrease in depressive symptomatology (within the non-depressed range of the GDS-15) and an increase in perceived mental health functioning, regardless of intervention allocation. These improvements were also evident at the follow-up period for participants in both intervention allocation groups. Conclusion:Our findings suggest that the standard time-based Green Prescription and a modified pedometer-based Green Prescription are both effective in maintaining and improving mental health in non-depressed, previously low-active older adults.

Ham, P. & Allen, C. 2012. Adolescent health screening and counseling. American Family Physician 86(12) 1109-16.

Serious health problems, risky behavior, and poor health habits persist among adolescents despite access to medical care. Most adolescents do not seek advice about preventing leading causes of morbidity and mortality in their age group, and physicians often do not find ways to provide it. Although helping adolescents prevent unintended pregnancy, sexually transmitted infections, unintentional injuries, depression, suicide, and other problems is a community-wide effort, primary care physicians are well situated to discuss risks and offer interventions. Evidence supports routinely screening for obesity and depression, offering testing for human immunodeficiency virus infection, and screening for other sexually transmitted infections in some adolescents. Evidence validating the effectiveness of physician counseling about unintended pregnancy, gang violence, and substance abuse is scant. However, physicians should use empathic, personal messages to communicate with adolescents about these issues until studies prove the benefits of more specific methods. Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents and of confidentiality.

Hardy, S. & Gray, R. 2012. Assessing cardiovascular risk in patients with severe mental illness. Nursing Standard 26(45) 41-48.

Cardiovascular disease (CVD) is a term mainly used to describe disorders affecting the heart and/or the arteries and veins that are associated with atherosclerosis (the build up of fatty deposits and debris inside blood vessels). CVDs, such as coronary heart disease and peripheral arterial disease, are long-term conditions, but acute events such as myocardial infarction can occur suddenly when a vessel supplying blood to the heart or brain becomes blocked or ruptures. Lifestyle factors and the side effects of antipsychotic medication result in a high incidence of CVD in people with severe mental illness. This article explores how nurses in primary and secondary care can identify CVD risk factors and help patients reduce these risks.

Gibson, M., Carek, P. J. & Sullivan, B. 2011. Treatment of co-morbid mental illness in primary care: how to minimize weight gain, diabetes, and metabolic syndrome. International Journal of Psychiatry in Medicine 41(2) 127-42.

In patients with mental illness the increased risk from cardiovascular disease

appears to be related to the increased incidence of obesity, hypertension, and diabetes mellitus. Barriers to the medical care in this patient population include diminished adherence to treatment and preventative recommendations, lack of willingness to engage in self-care activities, decreased access to affordable medical care, underestimation of risk by physicians, and adverse effects of commonly prescribed psychiatric medications. When managing patients with mental illness it is necessary to estimate the patient's metabolic and cardiovascular risk, monitor BMI, waist circumference, fasting glucose, and lipid profile regularly, evaluate psychiatric medications metabolic risk, and choose less "metabolically threatening" drugs. The promotion of healthy lifestyle choices among persons with serious mental illness is essential not only as part of their recovery, but as an integral part of preventing metabolic changes and weight gain linked to their illness and medication side effects. In patients with mental illness and co-morbid diabetes, metabolic syndrome, and obesity, psychiatrist and primary care clinicians should collaborate to establish a plan for healthy lifestyle habits (diet and activity regimen), encourage weight loss, and follow-up regularly using multispecialty teams to improve management.

Sajatovic, M., Dawson, N. V., Perzynski, A. T., et al. 2011. Optimizing care for people with serious mental illness and comorbid diabetes. Psychiatric Services 62(9) 1001-1003.

Diabetes and obesity among patients with serious mental illness are common. Use of second-generation antipsychotics compounds risk, and widely prevalent unhealthy behaviors further contribute to negative outcomes. This column describes Targeted Training in Illness Management, a group-based psychosocial treatment that blends psychoeducation, problem identification, goal setting, and behavioral modeling and reinforcement. The intervention has been adapted to the primary care setting and is targeted at individuals with serious mental illness and diabetes. A key feature of the intervention is the use of peer educators with serious mental illness and diabetes to teach and model self-management. Promising results from a 16-week trial are reported.

Seeman, M. V. 2011. Preventing breast cancer in women with schizophrenia. Acta Psychiatrica Scandinavica 123(2) 107-17.

OBJECTIVE: To record risk factors for breast cancer in women with schizophrenia and recommend preventive actions.METHOD: A PubMed literature search (from 2005 to 2010) was conducted, using the search terms 'schizophrenia', 'antipsychotics', 'breast cancer' and 'risk factors'.RESULTS: Several risk factors of relevance to schizophrenia were identified: obesity, elevated prolactin levels, low participation in mammography screening, high prevalence of diabetes, comparatively low parity, low incidence of breastfeeding, social disadvantage, high levels of smoking and alcohol consumption, low activity levels.CONCLUSION: Awareness of breast cancer risk should lead to more accurate risk ascertainment, stronger linkage with primary care, regular monitoring and screening, judicious choice and low dose of antipsychotic treatment, concomitant use of adjunctive cognitive and psychosocial therapies, referral to diet and exercise

programmes as well as smoking and drinking cessation programmes, avoidance of hormonal treatment and discussion with patient and family about the pros and cons of preventive measures in high-risk women. Psychiatrists are in a position to reverse many of the identified risk factors.

Lin, J. D., Sung, C. L., Lin, L. P., et al. 2010. Perception and experience of primary care physicians on Pap smear screening for women with intellectual disabilities: a preliminary finding. Research in Developmental Disabilities 31(2) 440-5.

This study aims to establish evidence-based data to explore the perceptions and experience of primary care physicians in the Pap smear screening provision for women with intellectual disabilities (ID), and to analyze the associated factors in the delivery of screening services to women with ID in Taiwan. Data obtained by a cross-sectional survey by a structured, self-administered questionnaire (12 perceptional issues), and were posted to all primary care settings (N=168) which provided Pap smear tests for women with ID in Taichung and I-Lan counties in Taiwan, Republic of China during the period of 2009. The vital primary care physician of each healthcare setting was the main respondent of the questionnaire. Finally, there were 69 valid questionnaires returned, giving a response rate of 41.7%. The main findings showed that 72.5% medical care settings provide Pap smear services and 51.5% have practical experience on conducting the tests for women with ID. Among the respondents, nearly 90% primary care physicians expressed that women with ID need Pap smear test regularly. With regard to the associated factors in the delivery of Pap smear screening services to women with ID. The study found that experienced healthcare settings in Pap smear tests for women with ID were more likely to be in public healthcare settings, felt confident in providing screening tests, having a rapid screening program and having a reminding follow-up system. Those respondents felt necessity in Pap smear test for women with ID were more likely to express it is needed to set up a special screening clinic for this group of women. The present study suggests that women with ID need thoughtful, well-coordinated care from primary care physicians, to increase access to health care providers may be helpful in improving Pap screening tests for this population.

De Hert, M., Dekker, J. M., Wood, D., et al. 2009. Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). European Psychiatry: the Journal of the Association of European Psychiatrists 24(6) 412-24.

People with severe mental illnesses, such as schizophrenia, depression or bipolar disorder, have worse physical health and reduced life expectancy compared to the general population. The excess cardiovascular mortality associated with schizophrenia and bipolar disorder is attributed in part to an increased risk of the modifiable coronary heart disease risk factors; obesity, smoking, diabetes, hypertension and dyslipidaemia. Antipsychotic medication and possibly other psychotropic medication like antidepressants can induce weight gain or worsen other

metabolic cardiovascular risk factors. Patients may have limited access to general healthcare with less opportunity for cardiovascular risk screening and prevention than would be expected in a non-psychiatric population. The European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) published this statement with the aim of improving the care of patients suffering from severe mental illness. The intention is to initiate cooperation and shared care between the different healthcare professionals and to increase the awareness of psychiatrists and primary care physicians caring for patients with severe mental illness to screen and treat cardiovascular risk factors and diabetes.

Morden, N. E., Mistler, L. A., Weeks, W. B., et al. 2009. Health care for patients with serious mental illness: family medicine's role. Journal of the American Board of Family Medicine : JABFM 22(2) 187-195.

Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.

Cahill, M. & Jackson, A. 2008. Monitoring the physical health of individuals with serious mental illness. Irish Journal of Psychological Medicine 25(3) 108-115.

Developing effective models of identifying and managing physical ill health amongst mental health service users has become an increasing concern for psychiatric service providers. This article sets out the general professional and Irish statutory obligations to provide physical health monitoring services for individuals with serious mental illness. Review and summary statements are provided in relation to the currently available guidelines on physical health monitoring.

Katon, W. J., Russo, J. E., Von Korff, M., et al. 2008. Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care 31(6) 1155-9.

OBJECTIVE: The purpose of this study was to examine the 5-year effects on total health care costs of the Pathways depression intervention program for patients with diabetes and comorbid depression compared with usual primary care.RESEARCH DESIGN AND METHODS: The Pathways Study was conducted in nine primary care practices of a large HMO and enrolled 329 patients with diabetes and comorbid major depression. The current study analyzed the differences in long-term medical costs between intervention and usual care patients. Participants were randomly assigned to a nurse depression intervention (n = 164) or to usual primary care (n = 165). The intervention included education about depression, behavioral activation, and a choice of either starting with support of antidepressant medication treatment by the primary care doctor or problem-solving therapy in primary care. Interventions were provided for up to 12 months, and the main outcome measures are health costs over a 5-year period.RESULTS: Patients in the intervention arm of the study had improved depression outcomes and trends for reduced 5-year mean total medical costs of -$3,907 (95% CI -$15,454 less to $7,640 more) compared with usual care patients. A sensitivity analysis found that these cost differences were largely explained by the patients with depression and the most severe medical comorbidity.CONCLUSIONS: The Pathways depression collaborative care program improved depression outcomes compared with usual care with no evidence of greater long-term costs and with trends for reduced costs among the more severely medically ill patients with diabetes.

Wilkinson, J. E. & Cerreto, M. C. 2008. Primary care for women with intellectual disabilities. Journal of the American Board of Family Medicine: JABFM 21(3) 215-22.

Women with intellectual disabilities (ID) need thoughtful, well-coordinated care from primary care physicians. They are particularly susceptible to experiencing disparities in care because of varied participation in shared decision making. This review of the current literature comments on the quantity and quality of existing studies regarding several key women's health issues: menstrual disorders, cervical and breast cancer screening, contraception, and osteoporosis. A review of the current thinking regarding ethical and legal issues in medical decision making for these women is also provided. We found that there are several high-quality studies recommending early and frequent screening for osteoporosis, which is more common in women with ID. Smaller and fewer studies comment specifically on techniques for accomplishing the gynecological examination in women with ID, although the cervical cancer screening recommendation should be individualized for these patients. Consensus data on the management of menstrual problems and contraception in women with ID is provided. There are some data on breast cancer incidence but few articles on methods to improve screening rates in women with ID. [References: 59]

Appendix: Search strategy1 exp Mental Disorders/

2 ((serious or severe or major) adj (mental or psychiatric) adj (illness or disorder* or health or "ill health" or issue* or condition*)).ti.3 SMI.tw.4 1 or 2 or 35 exp Primary Health Care/6 primary care.tw.7 primary health?care.tw.8 exp Family Practice/9 exp General Practice/10 general practi*.tw.11 family practi*.tw.12 family physician*.tw.13 exp Ambulatory Care/14 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 1315 exp OBESITY/16 exp OVERWEIGHT/17 obes*.ti.18 exp Weight Gain/19 exp DIABETES MELLITUS/20 exp Coronary Disease/21 exp Neoplasms/22 cancer*.ti.23 exp STROKE/24 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 2325 exp PRIMARY PREVENTION/26 24 and 2527 exp Weight Loss/28 26 or 2729 4 and 14 and 2830 limit 29 to (english language and yr="2008 -Current")