[Neuropsychiatric associations in Belgium: from foundation to separation (1869-2008)]. / Neuropsychiatrische verenigingen in België: van ontstaan tot splitsing (1869-2008).

Background Professional associations have traditionally been important to the specialization process and identity of medical specialists. Psychiatry and neurology share common origins in the 19th century and subsequently went through a major evolution. However, relatively little is known about the role of neuropsychiatric associations. Aim To provide a concise historical overview of the Belgian neuropsychiatric associations and understand the factors that mattered in their formation and dissolution. Method Descriptive research based on oral testimonies, archival material, journals of the concerned associations and secondary literature. Results In 1869, the then ‘alienists’ founded the first Belgian psychiatric association. Subsequently, three fault lines – professional associations versus scientific associations, regional versus national associations, neurological versus psychiatric associations – led to the current neurological and psychiatric associations in Belgium. Conclusion Over time, the neuropsychiatric associations have helped define the identity of neurology and psychiatry. On the other hand, the associations themselves have been subject to both substantive factors, i.e. the evolution of the discipline, and non-substantive factors. The latter are specific to Belgium and concern linguistic struggles and a historically created split between scientific associations and professional associations.

[Sustainability in Flemish and Dutch mental health care]. / Duurzaamheid in de Vlaamse en Nederlandse ggz.

BACKGROUND: The Flemish and Dutch (mental) health sectors cause greenhouse gas emissions and therefore will have to make an effort to reduce their climate impact. AIM: To assess whether differences can be found in the climate policies of Flemish and Dutch mental health institutions. METHOD: Descriptive research based on a sustainability questionnaire, in which concrete actions, objectives and ambitions in the field of sustainability were questioned at Flemish and Dutch mental health institutions. RESULTS: 59% and 38% of respectively the Flemish and Dutch institutions fully agreed that sustainability is a very important theme (with a main focus on sustainable energy transition and recycling in both regions). Statistically significant differences between both regions were only found with regard to fostering more sustainable commuting (stronger in Flanders; p < 0.0001). The climate impact of medicines and food, as well as investments in sustainable projects, received little attention. CONCLUSION: Although a substantial part of Flemish and Dutch mental health institutions consider sustainability (very) important, a systemic ‘transformation’ will be necessary to make them climate neutral.

[Somatic care in psychiatry : barriers perceived by patients and health professionals]. / Soins de santé somatiques en psychiatrie : barrières perçues par les patients et les professionnels de la santé.

Disparities in access to, use of and delivery of somatic health care contribute to widening gaps in morbidity and mortality between psychiatric patients and the general population. We conducted a qualitative semi-structured interview study with psychiatric patients and health professionals from different psychiatric care settings to understand these poor physical health outcomes. Optimal somatic follow-up of patients with severe mental illness seems to be hampered by (1) provider-related elements (attitude, training, experiences); (2) organisational aspects (equipment, infrastructure, staff, pharmacy, communication networks); (3) psychiatric patient-related elements and (4) financial barriers.There is an urgent need for integrated somatic and psychiatric health care systems and for cultural change. Psychiatrists and somatic health care providers continue to view the mental and physical health of their patients as mutually exclusive responsibilities. A range of system changes will improve the quality of somatic health care for these vulnerable patients.

Les disparités dans l'accès, l'utilisation et la prestation des soins de santé somatiques contribuent à creuser les écarts de morbidité et mortalité entre patients psychiatriques et la population générale. Nous avons mené une étude qualitative par entretiens semi-structurés auprès de patients psychiatriques et de professionnels de santé de différents lieux de soins psychiatriques afin de comprendre ces mauvais résultats en matière de santé physique. Le suivi somatique optimal des patients atteints d'une maladie mentale sévère semble entravé par des éléments : (1) liés aux prestataires de soins (attitude, formation, expériences); (2) en relation avec des aspects organisationnels (équipement, infrastructure, personnel, pharmacie, réseaux de communication); (3) inhérents aux caractéristiques des patients psychiatriques et (4) représentés par des obstacles financiers. Il est urgent de mettre en place des systèmes de soins de santé somatiques et psychiatriques intégrés et d'entamer un changement culturel. Les psychiatres et les prestataires de soins somatiques continuent de considérer la santé mentale et la santé physique de leurs patients comme des responsabilités mutuellement exclusives. Un changement de paradigme tendant vers une meilleure intégration permettra d'améliorer la qualité des soins de santé somatiques pour ces patients vulnérables.

[Euthanasia: opinions and experiences of Flemish psychiatrists working at a university]. / Euthanasie: opvattingen en ervaringen van universitair werkzame Vlaamse psychiaters.

BACKGROUND: Little is known about the attitude of Belgian psychiatrists and psychiatrists in training towards euthanasia for psychiatric reasons. AIM: To analyse opinions about and experiences with euthanasia in physicians from a university psychiatric hospital. METHOD: A mail with a questionnaire was sent to the 111 psychiatrists and psychiatrists in training from University Psychiatric Centre KU Leuven to assess their profile, opinions towards euthanasia in different cases and own experiences with requests for euthanasia in the last five years. RESULTS: The response rate was 45%. The majority of psychiatrists were accepting towards euthanasia, also in the case of psychiatric disorders (64%) or a combination of non-terminal somatic and psychosocial illness (60%). Religious psychiatrists were less accepting towards euthanasia than non-religious colleagues. Older psychiatrists (more than 20 years of working experience) were more open towards euthanasia than their younger colleagues, but less so than psychiatrists in training. Encounters with euthanasia were limited. CONCLUSION: The common attitude towards euthanasia in doctors from a tertiary psychiatric centre is accepting. More research in a broader population is recommended.

Polygenic liability for schizophrenia and childhood adversity influences daily-life emotion dysregulation and psychosis proneness.

OBJECTIVE: To test whether polygenic risk score for schizophrenia (PRS-S) interacts with childhood adversity and daily-life stressors to influence momentary mental state domains (negative affect, positive affect, and subtle psychosis expression) and stress-sensitivity measures. METHODS: The data were retrieved from a general population twin cohort including 593 adolescents and young adults. Childhood adversity was assessed using the Childhood Trauma Questionnaire. Daily-life stressors and momentary mental state domains were measured using ecological momentary assessment. PRS-S was trained on the latest Psychiatric Genetics Consortium schizophrenia meta-analysis. The analyses were conducted using multilevel mixed-effects tobit regression models. RESULTS: Both childhood adversity and daily-life stressors were associated with increased negative affect, decreased positive affect, and increased subtle psychosis expression, while PRS-S was only associated with increased positive affect. No gene-environment correlation was detected. There is novel evidence for interaction effects between PRS-S and childhood adversity to influence momentary mental states [negative affect (b = 0.07, P = 0.013), positive affect (b = -0.05, P = 0.043), and subtle psychosis expression (b = 0.11, P = 0.007)] and stress-sensitivity measures. CONCLUSION: Exposure to childhood adversities, particularly in individuals with high PRS-S, is pleiotropically associated with emotion dysregulation and psychosis proneness.

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection.

BACKGROUND: Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing. METHODS: The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. RESULTS: We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic. CONCLUSIONS: The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

[The stigmatisation of schizophrenia, psychosis and autism in the Flemish daily papers]. / Stigma rond schizofrenie, psychose en autisme in de Vlaamse dagbladen, 2013-2017.

BACKGROUND: A considerable social stigma is attached to psychiatric disorders. Evidence shows that the portrayal of schizophrenia in the media is particularly negative. It has been proposed to replace the term schizophrenia by psychosis susceptibility or psychosis spectrum disorder.
AIM: Follow-up of the study of the seven Flemish newspapers published between 2008-2012: to compare the degree of stigma in reporting of autism, schizophrenia and psychosis in the Flemish daily newspapers published between 2013-2017.
METHOD: Via the websites of the seven Flemish daily newspapers, we searched for all articles published between 2013 and 2017 containing the keywords autism, schizophrenia, psychosis and related terms. The collected articles (n = 5,337) were then graded to their stigmatising content.
RESULTS: In the collected articles the coverage of autism was mostly positive, whereas the coverage of schizophrenia was predominantly negative and of psychosis both positive and negative. The contrast between the reporting on autism and on schizophrenia was very substantial (p < 0.0001). The positive coverage of autism increased over time, the coverage of schizophrenia was negative in a stable way. The coverage of psychosis was only positive in the broadsheet newspapers.
CONCLUSION: The social stigma attached to schizophrenia and psychosis is poignantly reflected in the Flemish newspapers. The fact that a comparable disorder such as autism is depicted in a much more favorable way than schizophrenia indicates that a more positive image of schizophrenia is not only desirable but also achievable.

[Melatonin and sleep disorders: Overview of literature and testing in psychiatric practice]. / Melatonine en slaapstoornissen: literatuuroverzicht en toetsing aan de psychiatrische praktijk.

BACKGROUND: Sleep disorders are a frequent problem with an important impact on the quality of life. Given its physiological properties, melatonin is often associated with sleep disorders and their treatment. In addition, melatonin has been recognized by the European Medicines Agency (ema) since 2007 for primary insomnia in adults over 55 years of age for a maximum of 13 weeks.
AIM: Analysis of the international literature on the indication statements and effectiveness of melatonin for sleep disorders and their testing against practical use.
METHOD: A narrative literature study in PubMed, Cochrane and Web of Science, supplemented with a retrospective study of prescribing behavior within a university psychiatric hospital.
RESULTS: The current evidence for the use of melatonin for insomnia and circadian arrhythmias is low. We also noted that the effectiveness of melatonin for the recognized indication of primary insomnia was questioned by some guidelines and that the various studies were also heterogeneous in terms of outcome measures, indication statements and formulated advice. In addition, only 19.6% of the requirements in the retrospective study met the official ema indication.
CONCLUSION: This study shows that melatonin is mainly used off-label. Overall, there appears to be limited effectiveness of melatonin, which has an impact on the indication statements.

[Sublingual use of atropine for clozapine-induced sialorrhoea: literature review and two case reports]. / Sublinguaal atropine bij clozapine-geïnduceerde sialorroe: literatuuroverzicht en twee gevalsbeschrijvingen.

BACKGROUND: In patients taking clozapine, about 30% experience sialorrhoea, with its related potentially important medical and psychosocial implications. Until now, systemic treatments have been unsuccessful and also have unfavourable side-effects.
AIM: To examine the current evidence regarding the use of local atropine in clozapine-induced sialorrhoea (cis), as well as for sialorrhoea of other etiology.
METHOD: PubMed and Google Scholar were searched using the keywords 'sialorrhea', 'clozapine' and 'atropine' to investigate the use of sublingual atropine for cis, as well as for sialorrhoea of other etiology. Two patients are described and discussed.
RESULTS: Of 24 identified patients, 21 experienced a beneficial effect on cis with sublingually administered atropine eye drops or 1% ipratropium bromide nasal spray (0.03%). Side-effects, such as a dry mouth, unpleasant taste and short duration of action of the eye drops, were reported. Of the 67 patients treated with local atropine for sialorrhoea of other etiology, generally a beneficial effect and few side-effects were reported.
CONCLUSION: The sublingual administration of atropine appears to be effective in the treatment of cis, as well as in sialorrhoea of other etiology. The dose is usually 1-2 eye drops, two to three times per day.

Dropout from physical activity interventions in people living with HIV: a systematic review and meta-analysis.

Physical activity (PA) interventions have been shown to improve the health of people living with HIV (PLWH), yet treatment dropout poses an important challenge. We conducted a meta-analysis to investigate the prevalence and predictors of treatment dropout in PA interventions in PLWH. Electronic databases were searched for records up to September 2016. Randomized control trials of PA interventions in PLWH reporting dropout rates were included. Random effects meta-analysis and meta-regression analyses were employed. In 36 studies involving 49 PA intervention arms, 1128 PLWH were included (mean age = 41.6 years; 79.3% male; 39% White). The trim and fill adjusted treatment dropout rate was 29.3% (95% CI = 24.5-34.7%). There was a significant lower dropout rate in resistance training interventions compared with aerobic (p = 0.003) PA interventions, in studies utilizing supervised interventions throughout the study period (p < 0.001), and in studies using adequately qualified professionals (p < 0.001). Exerciser/participant variables that moderated higher dropout rates were a lower percentage of male participants (ß = 1.15, standard error (SE) = 0.49, z = 2.0, p = 0.048), a lower body mass index(BMI) (ß = 0.14, SE = 0.06, z = 2.16, p = 0.03), and a lower cardiorespiratory fitness (ß = 0.10, SE = 0.04, z = 2.7, p = 0.006). The dropout from PA interventions is much higher in PLWH than in many other populations with chronic morbidities. Qualified professionals (i.e., exercise physiologists, physical educators, or physical therapists) should be incorporated as key care providers in the multidisciplinary care of HIV/AIDS and should prescribe supervised PA for PLWH in order to enhance adherence and reduce the burden of HIV/AIDS. Special attention should be given men, those with a higher BMI, and those with a lower cardiorespiratory fitness.

Prescribing in schizophrenia and psychosis: Increasing polypharmacy over time.

INTRODUCTION: Diabetes, obesity, and metabolic syndrome are highly prevalent in patients with severe mental illness. Psychotropic polypharmacy is becoming increasingly prevalent within the UK. We determined the change in the number of psychotropic medications prescribed over time and trends in weight and fasting blood glucose. METHODS: One hundred ninety-five individuals with schizophrenia and psychosis on the Severe Mental Illness Register in Cheshire, UK, were followed up between 2004 and 2012. Individuals were identified through a semianonymised search of general practitioner registers. RESULTS: The total number of different medications prescribed increased from 140 in 2004 to 226 in 2012 with the mean number of medication groups per patient increasing from 0.71 to 1.15 (p < .001). The number of individuals on no medication reduced from 58.0% to 33.3%, OR 0.36 95% CI [0.24, 0.54], and those prescribed one medication increased from 20.5% to 31.8%, OR 1.93 95% CI [1.22-3.06]. Baseline body mass index was 28.9, increasing to 30.8 at 8-year follow-up, F(6.5), p = .003, with a significant corresponding increase in fasting blood glucose. CONCLUSION: In conclusion, we determined an increase in psychotropic polypharmacy over the follow-up period. Body mass index or fasting blood glucose increased over time. Clozapine and depot antipsychotic prescriptions were often not recorded in the general practitioner records.

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review.

OBJECTIVE: A recent meta-analysis showed that breast cancer probably is more common in female patients with schizophrenia than in the general population (effect size = 1.25, P < 0.05). Increasing experimental and epidemiological data have alerted researchers to the influence of prolactin (PRL) in mammary carcinogenesis. We therefore investigated the possible relationship between antipsychotic-induced hyperprolactinemia (HPRL) and breast cancer risk in female patients with schizophrenia. METHOD: A literature search (1950 until January 2015), using the MEDLINE database, was conducted for English-language published clinical trials to identify and synthesize data of the current state of knowledge concerning breast cancer risk (factors) in women with schizophrenia and its (their) relationship between HPRL and antipsychotic medication. RESULTS: Although an increasing body of evidence supports the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative (with risk ratios ranging from 0.70 to 1.9 for premenopausal women and from 0.76 to 2.03 for postmenopausal women). Moreover, these studies equally do not take into account the local production of PRL in breast epithelium, although amplification or overexpression of the local autocrine/paracrine PRL loop may be a more important mechanism in tumorigenesis. Until now, there is also no conclusive evidence that antipsychotic medication can increase the risk of breast malignancy and mortality. CONCLUSION: Other breast risk factors than PRL, such as nulliparity, obesity, diabetes mellitus, and unhealthy lifestyle behaviours (alcohol dependence, smoking, low physical activity), probably are of greater relevance in individual breast cancer cases within the population of female patients with schizophrenia.

Bone mineral density, osteoporosis, and fractures among people with eating disorders: a systematic review and meta-analysis.

OBJECTIVE: To provide meta-analytical evidence of bone mineral density (BMD), fractures, and osteoporosis rates in eating disorders (ED) vs. healthy controls (HCs). METHOD: Three independent authors searched major electronic databases from inception till August 2015 for cross-sectional studies reporting BMD in people with ED (anorexia nervosa, (AN); bulimia nervosa, (BN); eating disorders not otherwise specified, (EDNOS)) vs. HCs. Standardized mean differences (SMDs) ±95% and confidence intervals (CIs) were calculated for BMD, and odds ratios (ORs) for osteopenia, osteoporosis, and fractures. RESULTS: Overall, 57 studies were eligible, including 21 607 participants (ED = 6485, HCs = 15 122). Compared to HC, AN subjects had significantly lower BMD values at lumbar spine (SMD = -1.51, 95% CI = -1.75, -1.27, studies = 42), total hip (SMD = -1.56, 95%CI = -1.84, -1.28, studies = 23), intertrochanteric region (SMD = -1.80, 95%CI = -2.46, -1.14, studies = 7), trochanteric region (SMD = -1.05, 95%CI = -1.44, -0.66, studies = 7), and femoral neck (SMD = -0.98, 95%CI = -1.12, -0.77, studies = 20). Reduced BMD was moderated by ED illness duration and amenorrhea (P < 0.05). AN was associated with an increased likelihood of osteoporosis (OR = 12.59, 95%CI = 3.30-47.9, P < 0.001, studies = 4) and fractures (OR = 1.84, 95% CI = 1.17-2.89, I(2) = 56, studies = 6). No difference in BMD was found between BN and EDNOS vs. HC. CONCLUSION: People with AN have reduced BMD, increased odds of osteoporosis and risk of fractures. Proactive monitoring and interventions are required to ameliorate bone loss in AN.

[Prolactin, antipsychotics and breast cancer: is there a connection?]. / Prolactine, antipsychotica en borstkanker: is er een verband?

BACKGROUND: The use of antipsychotics can result in elevated prolactin levels or hyperprolactinemia. An increasing number of studies suggests that prolactin plays a role in mammary carcinogenesis, leading to concerns about a possible relationship between antipsychotics and breast cancer.
AIM: To provide an overview of recent literature regarding the relationship between prolactin, antipsychotics and breast cancer and an association between schizophrenia and breast cancer.
METHOD: We used PubMed to search for English- or Dutch-language articles concerning breast cancer risk (factors), prolactin, antipsychotics and schizophrenia.
RESULTS: Studies have not shown any causal link between antipsychotics and the development of breastcancer. Moreover, antipsychotic medication seems to have no influence on locally produced prolactin - which some experts believe plays a role in the tumor genesis - and certain antipsychotics actually provide protection against breast cancer. There are conflicting reports on the prevalence of breast cancer among patients with schizophrenia. Nevertheless, research has revealed that several well-known risk factors for breast cancer (such as an unhealthy lifestyle) are more prevalent in patients with schizophrenia.
CONCLUSION: There is no conclusive evidence that antipsychotic medication that raises prolactin levels increases the risk of breast cancer. Nevertheless, clinicians should always be cautious about prescribing antipsychotics for breast cancer patients. In our view, clinicians should always treat breast cancer risk factors as efficiently as possible, particularly when attending to patients who have schizophrenia.

The prevalence and predictors of type two diabetes mellitus in people with schizophrenia: a systematic review and comparative meta-analysis.

OBJECTIVE: To conduct a meta-analysis investigating the prevalence of type two diabetes mellitus (T2DM) in people with schizophrenia compared to controls. METHOD: Systematic review of electronic databases from inception till November 2014. Articles reporting the prevalence of T2DM in people with schizophrenia and healthy controls (without mental illness) were included. Two independent authors conducted searches and extracted data. A random effects relative risks (RR) meta-analysis was conducted. RESULTS: Twenty-five studies including 145,718 individuals with schizophrenia (22.5-54.4 years) and 4,343,407 controls were included. The prevalence of T2DM in people with schizophrenia was 9.5% (95% CI = 7.0-12.8, n = 145,718) and 10.75% (95% CI 7.44-14.5%, n = 2698) in studies capturing T2DM according to recognized criteria. The pooled RR across all studies was 1.82 (95% CI = 1.56-2.13; = 4,489,125). Subgroup analyses found a RR of 2.53 (95% CI = 1.68-3.799, n = 17,727) in studies ascertaining T2DM according to recognized criteria and RR 1.65 (95% CI = 1.34-2.03, n = 4,243,389) in studies relying on T2DM determined through medical records. CONCLUSION: People with schizophrenia are at least double the risk of developing T2DM according to recognized T2DM criteria. Proactive lifestyle and screening programmes should be given clinical priority.

How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview.

OBJECTIVE: High rates of smoking and nicotine dependence are associated with increased physical comorbidity and premature death in people with schizophrenia. We conducted a clinical overview to establish how smoking cessation should be promoted in practice. METHOD: Systematic clinical review of major electronic databases from inception till November 2014. RESULTS: A growing body of evidence supports pharmacological interventions to assist smoking cessation. The most promising evidence is for bupropion with several meta-analyses demonstrating its effectiveness. Currently, there is limited evidence demonstrating the effectiveness of nicotine replacement therapy (NRT) and varenicline, although this is likely to be due to the paucity of research. There are no consistent data to suggest that pharmacological interventions increase adverse events. Behavioural and psychosocial interventions also demonstrate promise, particularly when combined with pharmacotherapy. Careful monitoring of antipsychotic levels (in particular clozapine) is essential, and the promotion of physical activity may be useful to negate potential weight gain and diabetes risk following smoking cessation. CONCLUSION: Evidence from systematic reviews and meta-analyses suggests that smoking cessation interventions are effective in people with schizophrenia, although more long-term research is required. Promoting smoking cessation should be given utmost priority in clinical practice, and we offer practical strategies to facilitate this.

Weight gain and obesity in schizophrenia: epidemiology, pathobiology, and management.

OBJECTIVE: To review recent advances in the epidemiology, pathobiology, and management of weight gain and obesity in patients with schizophrenia and to evaluate the extent to which they should influence guidelines for clinical practice. METHOD: A Medline literature search was performed to identify clinical and experimental studies published in 2005-2014 decade. RESULTS: Weight gain and obesity increase the risk of adult-onset diabetes mellitus and cardiovascular disorders, non-adherence with pharmacological interventions, quality of life, and psychiatric readmissions. The etiology includes adverse effects of antipsychotics, pretreatment/premorbid genetic vulnerabilities, psychosocial and socioeconomic risk factors, and unhealthy lifestyle. Patients with schizophrenia have higher intake of calories in the form of high-density food and lower energy expenditure. The inverse relationship between baseline body mass index and antipsychotic-induced weight gain is probably due to previous antipsychotic exposure. In experimental models, the second-generation antipsychotic olanzapine increased the orexigenic stimulation of hypothalamic structures responsible for energy homeostasis. CONCLUSION: The management of weight gain and obesity in patients with schizophrenia centers on behavioural interventions using caloric intake reduction, dietary restructuring, and moderate-intensity physical activity. The decision to switch antipsychotics to lower-liability medications should be individualized, and metformin may be considered for adjunctive therapy, given its favorable risk-benefit profile.

Promotion of cardiorespiratory fitness in schizophrenia: a clinical overview and meta-analysis.

OBJECTIVE: Cardiorespiratory fitness (CRF) is a major modifiable risk factor for cardiovascular disease (CVD). We conducted a clinical overview to highlight the reduced CRF expressed as maximal oxygen uptake (VO2max) (or predicted) or peak oxygen uptake (VO2 peak) in people with schizophrenia compared to the general population. We also aimed to identify correlates of and clinical strategies to improve CRF. METHOD: We systematically searched major electronic databases from inception until November 2014. A meta-analysis calculating the standardised mean difference (SMD) was employed. RESULTS: CRF was significantly reduced in people with schizophrenia (n = 154) with a SMD of -0.96 (95% CI -1.29 to -0.64) (N = 5) compared to controls (n = 182). Negative symptoms, increased body mass index and female gender were negatively associated with CRF. Promoting physical activity may improve CRF in people with schizophrenia by up to 4-4.5 ml/kg/min following a 6-8 weeks programme (N = 4, n = 98). CONCLUSION: People with schizophrenia have a large and significantly reduced CRF. Given the overwhelming evidence for physical activity as the cornerstone of preventing and managing CVD in the general population, incorporating such interventions in the treatment of people with schizophrenia is justified and urgently required. We present clear practical strategies of how this can be achieved within clinical settings.

The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-analysis.

OBJECTIVE: To conduct a meta-analysis investigating the prevalence of pain in people with bipolar disorder (BD). METHOD: A systematic review and random effects meta-analysis searching major electronic databases from inception till 01/2014 in accordance with the PRISMA statement. We included articles reporting quantitative data on the prevalence of pain in people with BD with or without a healthy control group. Two independent authors conducted searches, extracted data, and completed methodological quality assessment. RESULTS: Twenty two cross-sectional studies were included, representing 12,375,644 individuals (BD n=171,352, n controls=12,204,292). The prevalence of pain in people with BD was 28.9% (95% CI=16.4-43.4%, BD n=171,352). The relative risk (RR) of pain in BD compared to controls was 2.14 (95% CI=1.67-2.75%, n=12,342,577). The prevalence of migraine was 14.2% (95% CI=10.6-18.3%, BD n=127,905), and the RR was 3.30 (95% CI=2.27-4.80%, n=6,732,220).About 23.7% (95% CI=13.1-36.3%, n=106,214) of people with BD experienced chronic pain. Age, percentage of males, methodological quality, and method of BD classification did not explain the observed heterogeneity. CONCLUSION: People with BD experience significantly increased levels of pain (particularly chronic pain and migraine). The assessment and treatment of pain should form an integral part of the management of BD.

Metabolic syndrome and metabolic abnormalities in patients with major depressive disorder: a meta-analysis of prevalences and moderating variables.

BACKGROUND: Individuals with depression have an elevated risk of cardiovascular disease (CVD) and metabolic syndrome (MetS) is an important risk factor for CVD. We aimed to clarify the prevalence and correlates of MetS in persons with robustly defined major depressive disorder (MDD). METHOD: We searched Medline, PsycINFO, EMBASE and CINAHL up until June 2013 for studies reporting MetS prevalences in individuals with MDD. Medical subject headings 'metabolic' OR 'diabetes' or 'cardiovascular' or 'blood pressure' or 'glucose' or 'lipid' AND 'depression' OR 'depressive' were used in the title, abstract or index term fields. Manual searches were conducted using reference lists from identified articles. RESULTS: The initial electronic database search resulted in 91 valid hits. From candidate publications following exclusions, our search generated 18 studies with interview-defined depression (n = 5531, 38.9% male, mean age = 45.5 years). The overall proportion with MetS was 30.5% [95% confidence interval (CI) 26.3-35.1] using any standardized MetS criteria. Compared with age- and gender-matched control groups, individuals with MDD had a higher MetS prevalence [odds ratio (OR) 1.54, 95% CI 1.21-1.97, p = 0.001]. They also had a higher risk for hyperglycemia (OR 1.33, 95% CI 1.03-1.73, p = 0.03) and hypertriglyceridemia (OR 1.17, 95% CI 1.04-1.30, p = 0.008). Antipsychotic use (p < 0.05) significantly explained higher MetS prevalence estimates in MDD. Differences in MetS prevalences were not moderated by age, gender, geographical area, smoking, antidepressant use, presence of psychiatric co-morbidity, and median year of data collection. CONCLUSIONS: The present findings strongly indicate that persons with MDD are a high-risk group for MetS and related cardiovascular morbidity and mortality. MetS risk may be highest in those prescribed antipsychotics.