Transcript Metabolic risks Psychiatric diagnosis (n=615)

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
[email protected]
Declaration of interest: Urban Ösby
Grant support:
Stockholm County Council, NARSAD, Bristol-Myers
Squibb
Advisory Board/Consultant:
AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Pfizer
Speakers Bureau:
AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Pfizer
Prevalence of Diagnosed Diabetes in General
Population Versus Schizophrenic Population
Diagnosed Diabetes, General Population
Diagnosed Diabetes, Schizophrenic Patients
30
Percent of
population
25
20
15
10
Schizophrenic:
General:
5
0
50-59 y
50-59 y
Harris et al. Diabetes Care. 1998; 21:518.
Mukherjee et al. Compr Psychiatry. 1996; 37(1):68-73.
60-69 y
60-74 y
70-74 y
75+ y
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
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
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
Goals: Lower Risk for CVD
• Blood cholesterol
– 10%  = 30%  in CHD (200-180)
• High blood pressure (> 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. 1998;97:1095-1102.
Identification of the Metabolic Syndrome
≥3 Risk Factors Required for Diagnosis
Risk Factor
Abdominal obesity
Men
Women
Triglycerides
HDL cholesterol
Men
Women
Blood pressure
Fasting blood glucose
HDL = high-density lipoprotein.
NCEP III. Circulation. 2002;106:3143-3421.
Defining Level
Waist circumference
>40 in (>102 cm)
>35 in (>88 cm)
150 mg/dL (1.69mmol/L)
<40 mg/dL (1.03mmol/L)
<50 mg/dL (1.29mmol/L)
130/85 mm Hg
110 mg/dL (6.1mmol/L)
Schizophrenia:
Natural Causes of Death
• Higher standardized mortality rates than the general population
from:
–
–
–
–
Diabetes
Cardiovascular disease
Respiratory disease
Infectious diseases
2.7x
2.3x
3.2x
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. 2000;45:21-28.
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 (GAF+CGI), 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
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?
Psychiatric diagnosis
(n=615)
Diagnosis:
N
%
M/F
Age
Schizophrenia
328
53
57/43
46.6
Other psychosis
187
30
44/56
45.9
Other diagnoses
100
16
45/55
48.5
Controls
5580
41/59
56.1
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
Waist circumference in cm
125
100
75
50
Schizophrenia***
Other psych.***
Other/unspec.***
* P<0,05, ** P<0.01, *** P<0,001, ns: not significant
Controls
Fasting Glucose in mmol/L
7,0
6,0
5,0
4,0
3,0
Schizophrenia***
Other psych.***
Other/unspec.***
* P<0,05, ** P<0.01, *** P<0,001, ns: not significant
Controls
Fasting Glucose ≥ 5.6
50%
40%
30%
20%
10%
0%
Schizophrenia
Other psychosis
Other/unspec.
Controls
Blood Pressure in mm Hg
175
150
ns
ns
ns
125
100
***
ns
ns
75
50
25
0
Systolic
Diastolic
* P<0,05, ** P<0.01, *** P<0,001, ns:not significant
Schizophrenia
Other psychosis
Other/unspec.
Controls
Body Mass Index
60%
Schizophrenia
Other psychosis
40%
Other/unspec.
Controls
20%
0%
<25
25-29,9
30-34,9
≥35
Body Mass Index
34,0
32,0
30,0
28,0
26,0
24,0
22,0
20,0
Schizophrenia***
Other psych.***
Other/unspec.***
* P<0,05, ** P<0.01, *** P<0,001, ns: not significant
Controls
Smoking
60%
40%
20%
0%
Current
Schizophrenia
Former
Other psychosis
Never
Other/unspec.
Controls
Snuff
100,0%
80,0%
60,0%
40,0%
20,0%
0,0%
Current
Schizophrenia
Former
Other psychosis
Never
Other/unspec.
Controls
Metabolic syndrome according to IDF criteria
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
Schizophrenia
Other psychosis
Other/unspec.
Lipids
6
Schizophrenia
Other psychosis
Other/unspec.
5
4
3
2
1
0
Cholesterol
HDL
LDL
Triglycerides
General health
60%
40%
20%
0%
Very good
Schizophrenia
Moderately
good
Neither-nor
Other psychosis
Moderately
bad
Other/unspec.
Very bad
Controls
Heredity for metabolic
disorders, %
SZ
PS
Other
Cardiac disorder
48
47
51
Elevated BP
49
55
54
DM
25
22
26
Obesity
30
28
34
Ctrl
48
Present antipsychotic drugs
(n=615)
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 %