Joseph M. Cerimele

Associations between health risk behaviors and symptoms of schizophrenia and bipolar disorder: a systematic review☆ , ☆☆ ,★,★★

OBJECTIVE To systematically review the literature to determine if health risk behaviors in patients with schizophrenia or bipolar disorder are associated with subsequent symptom burden or level of functioning. METHOD Using the PRISMA systematic review method we searched PubMed, Cochrane, PsychInfo and EMBASE databases with key words: health risk behaviors, diet, obesity, overweight, BMI, smoking, tobacco use, cigarette use, sedentary lifestyle, sedentary behaviors, physical inactivity, activity level, fitness, sitting AND schizophrenia, bipolar disorder, bipolar illness, schizoaffective disorder, severe and persistent mental illness, and psychotic to identify prospective, controlled studies of greater than 6 months duration. Included studies examined associations between sedentary lifestyle, smoking, obesity, physical inactivity and subsequent symptom severity or functional impairment in patients with schizophrenia or bipolar disorder. RESULTS Eight of the 2130 articles identified met inclusion criteria and included 508 patients with a health risk behavior and 825 controls. Six studies examined tobacco use, and two studies examined weight gain/obesity. Seven studies found that patients with schizophrenia or bipolar illness and at least one health risk behavior had more severe subsequent psychiatric symptoms and/or decreased level of functioning. CONCLUSION Tobacco use and weight gain/obesity may be associated with increased severity of symptoms of schizophrenia and bipolar disorder or decreased level of functioning.

The prevalence of bipolar disorder in general primary care samples: a systematic review

OBJECTIVE To obtain an estimate of the prevalence of bipolar disorder in primary care. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed. RESULTS We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients. CONCLUSION In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings. Prevalence estimates from studies using screening measures that have been found to have low positive predictive value were generally higher than those found using structured interviews.

Long-term Risk of Dementia in Persons With Schizophrenia: A Danish Population-Based Cohort Study.

IMPORTANCE Although schizophrenia is associated with several age-related disorders and considerable cognitive impairment, it remains unclear whether the risk of dementia is higher among persons with schizophrenia compared with those without schizophrenia. OBJECTIVE To determine the risk of dementia among persons with schizophrenia compared with those without schizophrenia in a large nationwide cohort study with up to 18 years of follow-up, taking age and established risk factors for dementia into account. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study of more than 2.8 million persons aged 50 years or older used individual data from 6 nationwide registers in Denmark. A total of 20 683 individuals had schizophrenia. Follow-up started on January 1, 1995, and ended on January 1, 2013. Analysis was conducted from January 1, 2015, to April 30, 2015. MAIN OUTCOMES AND MEASURES Incidence rate ratios (IRRs) and cumulative incidence proportions (CIPs) of dementia for persons with schizophrenia compared with persons without schizophrenia. RESULTS During 18 years of follow-up, 136 012 individuals, including 944 individuals with a history of schizophrenia, developed dementia. Schizophrenia was associated with a more than 2-fold higher risk of all-cause dementia (IRR, 2.13; 95% CI, 2.00-2.27) after adjusting for age, sex, and calendar period. The estimates (reported as IRR; 95% CI) did not change substantially when adjusting for medical comorbidities, such as cardiovascular diseases and diabetes mellitus (2.01; 1.89-2.15) but decreased slightly when adjusting for substance abuse (1.71; 1.60-1.82). The association between schizophrenia and dementia risk was stable when evaluated in subgroups characterized by demographics and comorbidities, although the IRR was higher among individuals younger than 65 years (3.77; 3.29-4.33), men (2.38; 2.13-2.66), individuals living with a partner (3.16; 2.71-3.69), those without cerebrovascular disease (2.23; 2.08-2.39), and those without substance abuse (1.96; 1.82-2.11). The CIPs (95% CIs) of developing dementia by the age of 65 years were 1.8% (1.5%-2.2%) for persons with schizophrenia and 0.6% (0.6%-0.7%) for persons without schizophrenia. The respective CIPs for persons with and without schizophrenia were 7.4% (6.8%-8.1%) and 5.8% (5.8%-5.9%) by the age of 80 years. CONCLUSIONS AND RELEVANCE Individuals with schizophrenia, especially those younger than 65 years, had a markedly increased relative risk of dementia that could not be explained by established dementia risk factors.

Does varenicline worsen psychiatric symptoms in patients with schizophrenia or schizoaffective disorder? A review of published studies.

OBJECTIVE To review published cases and prospective studies describing the use of varenicline in patients with schizophrenia and schizoaffective disorder. DATA SOURCES PubMed, PsychINFO, and the Cochrane Database were searched in July 2011 using the key words schizophrenia, schizoaffective disorder, psychosis, positive symptoms, negative symptoms, aggression, hostility, suicidal ideation AND varenicline to identify reports published between January 2006 and July 2011 in English. STUDY SELECTION Five case reports, 1 case series, 1 retrospective study, 10 prospective studies (17 publications), and 1 meeting abstract describing the use of varenicline in patients with schizophrenia or schizoaffective disorder were identified. Review articles and articles describing findings other than the use of varenicline in patients with schizophrenia or schizoaffective disorder were excluded. Thirteen reports were included in the final analysis. DATA EXTRACTION Information on each studys patient population, age, diagnosis, medication treatment, tobacco use history, adverse effects, and outcome was collected from the published reports. RESULTS Of the 260 patients with schizophrenia or schizoaffective disorder who received varenicline in these published reports, 13 patients (5%) experienced the onset or worsening of any psychiatric symptom, although 3 of the 13 patients experienced a very brief negative effect after 1 dose. No patients experienced suicidal ideation or suicidal behaviors. CONCLUSIONS Published reports suggest that, in most stable, closely monitored patients with schizophrenia or schizoaffective disorder, varenicline treatment is not associated with worsening of psychiatric symptoms. Current, prospective studies are assessing effectiveness and further assessing safety in this population.

Psychiatric–Medical ComorbidityThe prevalence of bipolar disorder in general primary care samples: a systematic review☆☆☆

OBJECTIVE To obtain an estimate of the prevalence of bipolar disorder in primary care. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed. RESULTS We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients. CONCLUSION In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings. Prevalence estimates from studies using screening measures that have been found to have low positive predictive value were generally higher than those found using structured interviews.

Serious Mental Illness and Risk for Hospitalizations and Rehospitalizations for Ambulatory Care-sensitive Conditions in Denmark: A Nationwide Population-based Cohort Study.

Background:Hospitalizations for ambulatory care-sensitive conditions (ACSCs) and early rehospitalizations increase health care costs. Objectives:To determine if individuals with serious mental illnesses (SMIs) (eg, schizophrenia or bipolar disorder) are at increased risk for hospitalizations for ACSCs, and rehospitalization for the same or another ACSC, within 30 days. Research Design:Population-based cohort study. Participants:A total of 5.9 million Danish persons aged 18 years and older between January 1, 1999 and December 31, 2013. Measures:The Danish Psychiatric Central Register provided information on SMI diagnoses and the Danish National Patient Register on hospitalizations for ACSCs and 30-day rehospitalizations. Results:SMI was associated with increased risk for having any ACSC-related hospitalization after adjusting for demographics, socioeconomic factors, comorbidities, and prior primary care utilization [incidence rate ratio (IRR): 1.41; 95% confidence interval (95% CI), 1.37–1.45]. Among individual ACSCs, SMI was associated with increased risk for hospitalizations for angina (IRR: 1.14, 95% CI, 1.04–1.25), chronic obstructive pulmonary disease/asthma exacerbation (IRR: 1.87; 95% CI, 1.74–2.00), congestive heart failure exacerbation (IRR: 1.25; 95% CI, 1.16–1.35), and diabetes (IRR: 1.43; 95% CI, 1.31–1.57), appendiceal perforation (IRR: 1.49; 95% CI, 1.30–1.71), pneumonia (IRR: 1.72; 95% CI, 1.66–1.79), and urinary tract infection (IRR: 1.70; 95% CI, 1.62–1.78). SMI was also associated with increased risk for rehospitalization within 30 days for the same (IRR: 1.28; 95% CI, 1.18–1.40) or for another ACSC (IRR: 1.62; 95% CI, 1.49–1.76). Conclusion:Persons with SMI are at increased risk for hospitalizations for ACSCs, and after discharge, are at increased risk for rehospitalizations for ACSCs within 30 days.

The Prevalence of Bipolar Disorder in Primary Care Patients With Depression or Other Psychiatric Complaints: A Systematic Review

BACKGROUND Bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints has been measured in several studies but has not been systematically reviewed. OBJECTIVE To systematically review studies measuring bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints. METHODS We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method in January 2013. We searched 7 databases using a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in adult primary care patients with a prior diagnosis of depression or had an alternate psychiatric complaint. RESULTS Our search yielded 5595 unique records. Seven cross-sectional studies met our inclusion criteria. The percentage of primary care patients with bipolar disorder was measured in 4 studies of patients with depression, 1 study of patients with trauma exposure, 1 study of patients with any psychiatric complaint, and 1 study of patients with medically unexplained symptoms. The percentage of patients with bipolar disorder ranged from 3.4%-9% in studies using structured clinical interviews and from 20.9%-30.8% in studies using screening measures. CONCLUSIONS Bipolar disorder likely occurs in 3%-9% of primary care patients with depression, a trauma exposure, medically unexplained symptoms, or a psychiatric complaint. Screening measures used for bipolar disorder detection overestimate the occurrence of bipolar disorder in primary care owing to false positives.

The presentation, recognition and management of bipolar depression in primary care.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Presenting symptoms of women with depression in an obstetrics and gynecology setting.

OBJECTIVE: To describe the presenting symptoms of women with depression in two obstetrics and gynecology clinics, determine depression diagnosis frequency, and examine factors associated with depression diagnosis. METHODS: Data were extracted from charts of women screening positive for depression in a clinical trial testing a collaborative care depression intervention. Bivariate and multivariable analyses examined patient factors associated with the diagnosis of depression by an obstetrician–gynecologist (ob-gyn). RESULTS: Eleven percent of women with depression presented with a psychologic chief complaint but another 30% mentioned psychologic distress. All others noted physical symptoms only or presented for preventive care. Ob-gyns did not identify 60% of women with a depression diagnosis. Depression severity was similar in women who were or were not diagnosed by their ob-gyns. Bivariate analyses showed four factors significantly associated with depression diagnosis: reporting a psychologic symptom as the chief complaint or associated symptom (72% compared with 18.6%, P<.001), younger age (35.5 years compared with 40.8 years, P<.005), being within 12 months postpartum (13.9% compared with 2.8%, P<.005), and a primary care-oriented visit (72% compared with 30%, P<.001). Multivariable analysis showed that reporting a psychologic symptom (adjusted odds ratio [OR] 8.90, 95% confidence interval [CI] 4.15–19.10, P<.001), a primary care oriented visit (adjusted OR 2.46, 95% CI 1.14–5.29, P=.03), and each year of increasing age (adjusted OR 0.96, 95% CI 0.93–0.96, P=.02) were significantly associated with a depression diagnosis. CONCLUSION: The majority of women with depression presented with physical symptoms; most women with depression were not diagnosed by their ob-gyn, and depression severity was similar in those diagnosed and those not diagnosed. LEVEL OF EVIDENCE: III

Pain in primary care patients with bipolar disorder.

Birgenheir et al [1] found that a chart diagnosis of a chronic pain condition occurred approximately two times as often in veterans with a documented diagnosis of bipolar disorder compared to those without bipolar disorder. These findings are important for addressing the overall health of patients with bipolar disorder [1]. The authors noted that the veteran population was a limitation of their study. In an effort to expand the authors’ findings, we will describe our previously unreported findings on pain in primary care patients with bipolar disorder. We identified 740 primary care patients with bipolar disorder receiving care between January 2008 and December 2011in the Washington State Mental Health Integration Program (MHIP), a state wide clinical program serving patients with co-occurring medical and mental health needs in over 140 community health centers [2]. Cases of bipolar disorder were defined as having both the presence of a semi-structured Composite International Diagnostic Interview Version 3.0 [3] consistent with bipolar disorder and a clinician-documented bipolar disorder diagnosis. All patients enrolled in MHIP are assessed with baseline symptom questions, including a question about pain phrased as, “Is the patient being treated for a chronic pain condition, or does s/he describe pain that happens regularly and that interferes with daily functioning?”. We defined the presence of pain as answering “yes” to this question. Additional details of MHIP and of primary care patients with bipolar disorder treated in MHIP are described elsewhere [4]. The mean age of patients with bipolar disorder in MHIP was 39 years (S.D. 10.6), and 44% (n=326) were women. 641 of the 740 (87%) patients with bipolar disorder responded to the pain question. Almost half of the total patients with bipolar disorder (n=338, 46%) endorsed either current treatment for a pain condition or regular pain interfering with daily functioning. Other findings included a mean Patient Health Questionnaire 9 (PHQ-9) score of 18.1 (SD 5.9), suicidal ideation based on a score of 1 or more on item 9 of the PHQ-9 in 58% of patients, and significant psychosocial impairment, such as lack of a support person, in many patients with bipolar disorder [4]. We found that a high percentage of primary care patients with bipolar disorder enrolled in a collaborative care treatment program endorsed current pain symptoms or functional impairment related to pain. A previous report on patients enrolled in MHIP prior to October 31, 2010, showed that chronic pain was significantly associated with suicidal ideation measured by the