Scott Teasdale

Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic‐induced weight gain in first‐episode psychosis

AIM Initiating antipsychotic medication frequently induces rapid, clinically significant weight gain. We aimed to evaluate the effectiveness of a lifestyle and life skills intervention, delivered within 4 weeks of antipsychotic medication initiation, in attenuating weight gain in youth aged 14-25 years with first-episode psychosis (FEP). METHODS We undertook a prospective, controlled study in two early psychosis community services. Intervention participants (n = 16) received a 12-week individualized intervention delivered by specialist clinical staff (nurse, dietician and exercise physiologist) and youth peer wellness coaches, in addition to standard care. A comparison group was recruited from a similar service and received standard care (n = 12). RESULTS The intervention group experienced significantly less weight gain at 12 weeks compared to standard care (1.8 kg, 95% CI -0.4 to 2.8 vs. 7.8 kg, 4.8-10.7, P < 0.001). Thirteen per cent (2/16) of the intervention group experienced clinically significant weight gain (greater than 7% of baseline weight), while 75% (9/12) of the standard care group experienced this level of weight gain. Similar positive effects of the intervention were observed for waist circumference. CONCLUSIONS A lifestyle and life skills intervention delivered as part of standard care attenuated antipsychotic-induced weight gain in young people with FEP. The intervention was acceptable to the young people referred to the service. Such interventions may prevent the seeding of future disease risk and in the long-term help reduce the life expectancy gap for people living with serious mental illness.

Integrating physical activity as medicine in the care of people with severe mental illness

Australian & New Zealand Journal of Psychiatry, 49(8) People with serious mental illnesses (SMIs) are dying prematurely due to high levels of cardiovascular diseases, and exercise may be part of the solution to this major health inequity. Given the evidence for ‘exercise as medicine’ in general medical literature, we need to consider how physical activity can contribute to the management of people with SMIs. In this debate article, we raise the question how to integrate physical activity as medicine in the care of people with SMIs.

Solving a weighty problem: systematic review and meta-analysis of nutrition interventions in severe mental illness

BACKGROUND Nutrition interventions would appear fundamental for weight management and cardiometabolic risk reduction in people experiencing severe mental illness (SMI). Comprehensive evaluation of nutrition interventions is lacking. AIMS To subject randomised controlled trials of nutrition interventions in people with SMI to systematic review and meta-analysis, and to measure anthropometric and biochemical parameters and nutritional intake. METHOD An electronic database search identified trials with nutrition intervention components. Trials were pooled for meta-analysis. Meta-regression analyses were performed on anthropometric moderators. RESULTS Interventions led to significant weight loss (19 studies), reduced body mass index (17 studies), decreased waist circumference (10 studies) and lower blood glucose levels (5 studies). Dietitian-led interventions (6 studies) and studies delivered at antipsychotic initiation (4 studies) had larger effect sizes. CONCLUSIONS Evidence supports nutrition interventions as standard care in preventing and treating weight gain among people experiencing SMI.

Why moving more should be promoted for severe mental illness

www.thelancet.com/psychiatry Vol 2 April 2015 295 with expertise in exercise prescription and psychopathology. We advocate that individuals who are unable or unwilling to meet the goal of 150 min of moderate physical activity could still benefit from engaging in some physical activity. Findings of a 2013 meta-analysis of studies of the general population suggested that risk for premature mortality signifi cantly increases when adults sit for more than 7 h a day, indicating that recommendations should be as broad as possible. Therefore, people with severe mental illness should be advised to sit less and to break up sitting time throughout the day rather than focusing on compliance with general population guidelines. Health-care professionals should take immediate action and advise patients to sit less and move more. For example, people with severe mental illness might be advised to reduce prolonged sitting by standing or strolling for 1–2 min at least once an hour. Advice on how to accumulate time spent in light physical activity could include getting up from the chair and moving around during television commercial breaks, or adding 5 min walks throughout the day, for example walking short distances rather than using motorised transport. Although seemingly trivial, adopting small, incremental lifestyle changes can better position sedentary people with severe mental illness to transition to brief bouts of moderate intensity exercise. Such an approach will not be constrained by socioeconomic, environmental, and organisational barriers. Implementation of such interventions requires a shift in culture and system reform, from the design of mental health facilities through to changing staff attitudes. At a minimum, mental health professionals should briefly assess current exercise behaviours at every consultation, and discuss realistic and specifi c goals that could be adopted, with support and follow-up. Changes in physical and mental health parameters can then be monitored. Health recommendations for the general population should not be discarded, but reframed as aspirational goals. Small incremental improvements—sitting less and moving more—constitute real-world interventions to improve the health of people with severe mental illness.

A nutrition intervention is effective in improving dietary components linked to cardiometabolic risk in youth with first-episode psychosis.

Severe mental illness is characterised by a 20-year mortality gap due to cardiometabolic disease. Poor diet in those with severe mental illness is an important and modifiable risk factor. The present study aimed to (i) examine baseline nutritional intake in youth with first-episode psychosis (FEP), (ii) evaluate the feasibility and acceptability of nutritional intervention early in FEP and (iii) to evaluate the effectiveness of early dietary intervention on key nutritional end points. Participants were recruited over a 12-month period from a community-based programme specifically targeting young people aged 15-25 years with newly diagnosed FEP. Individual dietetic consultations and practical group sessions were offered as part of a broader lifestyle programme. Dietary assessments were conducted before and at the end of the 12-week intervention. Participants exceeded recommended energy and Na intakes at baseline. Retention within the nutrition intervention was 67 %, consistent with other interventions offered to FEP clients. There was a 47 % reduction in discretionary food intake (-94 g/d, P<0·001) and reductions in daily energy (-24 %, P<0·001) and Na (-26 %, P<0·001) intakes. Diet quality significantly improved, and the mean change was 3·6 (95 % CI 0·2, 6·9, P<0·05), although this finding was not significant after Bonferronis correction. Increased vegetable intake was the main factor contributing to improved diet quality. Nutrition intervention delivered shortly after initiation of antipsychotic medication is feasible, acceptable and effective in youth with FEP. Strategies to prevent weight gain and metabolic decline will contribute to prevent premature cardiometabolic disease in this vulnerable population.

Aerobic exercise capacity: an important correlate of psychosocial function in first episode psychosis

max) or by standardized exercisetests, such as walking-based protocols that measure total dis-tance achieved in a given timeframe. Vancampfort et al. (2)first reported an association between exercise capacity and glo-bal functioning in hospitalized patients with schizophrenia. Astrong relationship was found between the distance achievedon a standardized walk-test (a validated measure of aerobicexercise capacity) and the Global Assessment of Functioningscore (GAF) (2). Although causality cannot be establishedthrough a cross-sectional study, the findings provide furtherjustification for the inclusion of physical activity interventionsin schizophrenia, and the importance of examining changes inmaximal aerobic capacity, particularly given the potentialimpact that such strategies may have on physical health, men-tal health, and overall psychosocial functioning (3, 4).We aimed to replicate the findings of Vancampfort et al. (2)in a sample of young people experiencing a first episode of psy-chosis (FEP) attending a community treatment service in Syd-ney, Australia. Nineteen young people (19.9 2.4 years; 53%male) completed a staged submaximal exercise test on a cycleergometer within 4 weeks of referral to the service. Submaxi-mal exercise tests are a cheap, feasible, and valid alternative tomaximal exercise testing for both the general and clinical popu-lations. Submaximal exercise testing relies on heart rateresponse to a given workload, to estimate exercise capacity.The current study utilized the Young Men’s Christian Associa-tion (YMCA) protocol involving two, 3-min stages of continu-ous cycling at a cadence of 50 RPM.The mean estimated V0

The effects of vitamin and mineral supplementation on symptoms of schizophrenia: a systematic review and meta-analysis

BACKGROUND When used as an adjunctive with antipsychotics, certain vitamins and minerals may be effective for improving symptomatic outcomes of schizophrenia, by restoring nutritional deficits, reducing oxidative stress, or modulating neurological pathways. METHOD We conducted a systematic review of all randomized controlled trials (RCTs) reporting effects of vitamin and/or mineral supplements on psychiatric symptoms in people with schizophrenia. Random-effects meta-analyses were used to calculate the standardized mean difference between nutrient and placebo treatments. RESULTS An electronic database search in July 2016 identified 18 eligible RCTs, with outcome data for 832 patients. Pooled effects showed that vitamin B supplementation (including B6, B8 and B12) reduced psychiatric symptoms significantly more than control conditions [g = 0.508, 95% confidence interval (CI) 0.01-1.01, p = 0.047, I 2 = 72.3%]. Similar effects were observed among vitamin B RCTs which used intention-to-treat analyses (g = 0.734, 95% CI 0.00-1.49, p = 0.051). However, no effects of B vitamins were observed in individual domains of positive and negative symptoms (both p > 0.1). Meta-regression analyses showed that shorter illness duration was associated with greater vitamin B effectiveness (p = 0.001). There were no overall effects from antioxidant vitamins, inositol or dietary minerals on psychiatric symptoms. CONCLUSIONS There is preliminary evidence that certain vitamin and mineral supplements may reduce psychiatric symptoms in some people with schizophrenia. Further research is needed to examine how the benefits of supplementation relate to nutrient deficits and the impact upon underlying neurobiological pathways, in order to establish optimal nutrient formulations for improving clinical outcomes in this population. Future studies should also explore the effects of combining beneficial nutrients within multi-nutrient formulas.

Nutritional deficiencies and clinical correlates in first-episode psychosis: a systematic review and meta-analysis

Abstract Objective Diet is increasingly recognized as a potentially modifiable factor influencing the onset and outcomes of psychiatric disorders. Whereas, previous research has shown long-term schizophrenia is associated with various nutritional deficiencies, this meta-analysis aimed to determine the prevalence and extent of nutritional deficits in first-episode psychosis (FEP). Method A search of electronic databases conducted in July 2017 identified 28 eligible studies, examining blood levels of 6 vitamins and 10 minerals across 2612 individuals: 1221 individuals with FEP and 1391 control subjects. Meta-analyses compared nutrient levels in FEP to nonpsychiatric controls. Clinical correlates of nutritional status in patient samples were systematically reviewed. Results Significantly lower blood levels of folate (N = 6, n = 827, g = −0.624, 95% confidence interval [CI] = −1.176 to −0.072, P = .027) and vitamin D (N = 7, n = 906, g = −1.055, 95% CI = −1.99 to −0.119, P = .027) were found in FEP compared to healthy controls. Synthesis of clinical correlates found both folate and vitamin D held significant inverse relationships with psychiatric symptoms in FEP. There was also limited evidence for serum level reductions of vitamin C (N = 2, n = 96, g = −2.207, 95% CI = −3.71 to −0.71, P = .004). No differences were found for other vitamins or minerals. Conclusions Deficits in vitamin D and folate previously observed in long-term schizophrenia appear to exist from illness onset, and are associated with worse symptomology. Further research must examine the direction and nature of these relationships (ie, mediator, moderator, or marker) with clinical status in FEP. Future trials assessing efficacy of nutrient supplementation in FEP samples should consider targeting and stratifying for baseline deficiency.

Expanding collaborative care: integrating the role of dietitians and nutrition interventions in services for people with mental illness:

Objective: This article aims to draw mental health clinicians’ attention to the connections between nutrition and mental health, and the roles that Accredited Practising Dietitians play in improving mental and physical health through dietary change. Methods: Selective narrative review. Results: Unhealthy dietary practices are common in high prevalence and severe mental illness. Epidemiological evidence demonstrates that nutrients and dietary patterns impact on mental health. In addition, poor physical health is well documented in people with mental illness and the greatest contributor to the mortality gap. Dietary intervention studies demonstrate improved mental and physical health outcomes. Accredited Practising Dietitians translate nutrition science into practical advice to improve the nutritional status of patients with mental illness, and prevent and manage comorbidities in a variety of care settings. Conclusions: Medical Nutrition Therapy offers opportunities to improve the physical and mental health of people living with mental illness.

Diet as a hot topic in psychiatry: a population-scale study of nutritional intake and inflammatory potential in severe mental illness: Diet as a hot topic in psychiatry: a population-scale study of nutritional intake and inflammatory potential in severe mental illness

ically useful (95%). There has been significant concern that introducing a diagnosis of prolonged grief would increase the likelihood that clinicians will medicalize or pathologize grief. We found, however, that mental health providers who received information about PGD were no more likely to pathologize normative grief than those who did not receive this information in advance of evaluating standardized patients. Furthermore, clinicians who correctly diagnosed PGD were shown to be less likely to recommend antidepressants for individuals they accurately diagnosed with PGD andmore likely to recommend psychotherapies that have direct relevance to PGD symptoms, such as disbelief (emotion-focused therapy), loss of meaning (existential therapy), and persistent suffering (acceptance and commitment therapy). This may reflect clinicians’ perception that PGD is less biologically based than, for example, MDD. Although, like the DSM, the PGD tutorial did not offer treatment recommendations, it did describe risk factors that were psychological in nature,whichmayhave affected the recommendationsmade. This study also suggests the clinical value of using straightforward diagnostic criteria to distinguish pathological grief from other clinical presentations. The proposed PGD criteria are highly specific, which should reduce the risk of pathologizing normative grief reactions. At the same time, they are sufficiently sensitive to capture those in need. Under-recognition of PGD and misclassifying it as another diagnosis is likely to lead to suboptimal treatment. PGD improves when specific interventions, such as those recommended by the study participants, target unique pathological grief symptoms. The misdiagnosis of PGD as MDD or PTSD may promote the use of inappropriate interventions. Although this study was limited by a relatively small sample size and by the biases inherent in those who chose to participate, it demonstrates that PGD is perceived and shown to be clinically useful. We therefore believe that educating clinicians about PGD is likely to improve their ability to distinguish normal from pathological grief; to enhance communication between clinicians, patients, and their families; and to assist in the delivery of effective treatments for PGD. Wendy G. Lichtenthal, Paul K. Maciejewski, Caraline Craig Demirjian, Kailey E. Roberts, Michael B. First, DavidW. Kissane, Robert A. Neimeyer,William Breitbart, Elizabeth Slivjak, Greta Jankauskaite, Stephanie Napolitano, Andreas Maercker, Holly G. Prigerson Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medicine, New York, NY, USA; Monash University, Clayton, VIC, Australia; University of Memphis, Memphis, TN, USA; Columbia University Medical Center, New York, NY, USA; University of Zurich, Zurich, Switzerland