Metabolic risks in psychosis

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Metabolic risks in psychosis in Sweden
Urban Ösby MD, PhD, Senior Consultant Psykiatri
Nordöst, Stockholm County Council Department of
Clinical Neuroscience, Karolinska Institutet,
Stockholm, Sweden
urban.osby_at_sll.se
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Declaration of interest Urban Ösby
Grant support Stockholm County Council, NARSAD,
Bristol-Myers Squibb Advisory Board/Consultant A
straZeneca, Bristol-Myers Squibb, Eli Lilly,
Pfizer Speakers Bureau AstraZeneca,
Bristol-Myers Squibb, Eli Lilly, Pfizer
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Prevalence of Diagnosed Diabetes in General
Population Versus Schizophrenic Population
Percent of population
Schizophrenic
General
50-59 y
60-74 y
75 y
Harris et al. Diabetes Care. 1998
21518. Mukherjee et al. Compr Psychiatry. 1996
37(1)68-73.
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Mental Disorders and Smoking

• Higher prevalence (56-88 for patients with
  schizophrenia) of cigarette smoking (overall U.S.
  prevalence 25)
• More toxic exposure for patients who smoke (more
  cigarettes, larger portion consumed)
• Smoking is associated with increased insulin
  resistance
• Similar prevalence in bipolar disorder

George TP et al. Nicotine and tobacco use in
schizophrenia. In Meyer JM, Nasrallah HA, eds.
Medical Illness and Schizophrenia. American
Psychiatric Publishing, Inc. 2003 Ziedonis D,
Williams JM, Smelson D. Am J Med Sci.
2003(Oct)326(4)223-330
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Overview- THE PROBLEM

• Increased Morbidity and Mortality Associated with
  Serious Mental Illness (SMI)
• Increased Morbidity and Mortality Largely Due to
  Preventable Medical Conditions
• Metabolic Disorders, Cardiovascular Disease,
  Diabetes Mellitus
• High Prevalence of Modifiable Risk Factors
  (Obesity, Smoking)
• Epidemics within Epidemics (e.g., Diabetes,
  Obesity)
• Some Psychiatric Medications Contribute to Risk
• Established Monitoring and Treatment Guidelines
  to Lower Risk Are Underutilized in SMI Populations

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What are the Causes of Morbidity and Mortality in
People with Serious Mental Illness?

• While suicide and injury account for about 30-40
  of excess mortality, about 60 of premature
  deaths in persons with schizophrenia are due to
  natural causes
• Cardiovascular disease
• Diabetes
• Respiratory diseases
• Infectious diseases

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Goals Lower Risk for CVD

• Blood cholesterol
• 10 ? 30 ? in CHD (200-180)
• High blood pressure (gt 140 SBP or 90 DBP)
• 4-6 mm Hg ? 16 ? in CHD 42 ? in stroke
• Cigarette smoking cessation
• 50-70 ? in CHD
• Maintenance of ideal body weight (BMI 25)
• 35-55 ? in CHD
• Maintenance of active lifestyle (20-min walk
  daily)
• 35-55 ? in CHD

Hennekens CH. Circulation. 1998971095-1102.
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Identification of the Metabolic Syndrome
HDL high-density lipoprotein. NCEP III.
Circulation. 20021063143-3421.
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Schizophrenia Natural Causes of Death

• Higher standardized mortality rates than the
  general population from
• Diabetes 2.7x
• Cardiovascular disease 2.3x
• Respiratory disease 3.2x
• Infectious diseases 3.4x
• Cardiovascular disease associated with the
  largest number of deaths
• 2.3 X the largest cause of death in the general
  population

Osby U et al. Schizophr Res. 20004521-28.
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Swedish study of metabolic risks in psychosis

• Population-based recruitment from psychosis
  outpatient departments
• Prospective design with 3 years follow-up.
• Drug-naive patients included separately.
• Assessments
• 1) Diagnosis, social function (GAFCGI), present
  and previous medication
• 2) Weight, waist circumference, BMI, BP
• 3) Somatic health DM, cardiovascular disease,
  smoking, alcohol use etc.
• Lab 1) clinical Hb, glucose, lipids, TSH, etc
• 2) research serum plasma blood for DNA

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Metabolic risks
1. Metabolic adverse effects of antipsychotic,
mood stabilizing and anti-depressant medication
weight gain, DM, lipid disturbances, etc 2. Life
style factors related to the disease increased
smoking, increased alcohol use, less exercise,
etc 3. Overlapping risk genes between
psychiatric and metabolic disorders?
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Psychiatric diagnosis (n615)
Diagnosis N M/F Age Schizophrenia 328 53
57/43 46.6 Other psychosis 187 30 44/56 45.9 O
ther diagnoses 100 16 45/55 48.5 Controls 5580
41/59 56.1
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Psychiatric history

• SZ PS Other
• Age at start of treatment 28 31 31
• Months in hospital 15 8 7
• GAF 50 53 58
• Use of antipsychotics , 96 91 63

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Plt0,05, Plt0.01, Plt0,001, ns not
significant
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Plt0,05, Plt0.01, Plt0,001, ns not
significant
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ns ns ns
ns ns
Plt0,05, Plt0.01, Plt0,001, nsnot
significant
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Plt0,05, Plt0.01, Plt0,001, ns not
significant
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Smoking
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Snuff
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Metabolic syndrome according to IDF criteria
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Lipids
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General health
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Heredity for metabolic disorders,

• SZ PS Other Ctrl
• Cardiac disorder 48 47 51
• Elevated BP 49 55 54 DM 25 22
  26 48
• Obesity 30 28 34

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Present antipsychotic drugs (n615)
Olanzapine 124 20,2 Risperidone
111 18.0 Aripiprazol 72 11.7
Perfenazin 69 11.2 Haloperiodol 58 9.4
Zuclopentixol 56 9.1 Clozapine 52 8.5
Quetiapine 32 5.2 Flupentixol 21 3.4
Other/ND 30 4.9