Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

HOME   |   SEARCH   |   CURRENT ISSUE   |   PAST ISSUES

-

REVIEW ARTICLE

-

Volume 24

January - March 2008

Number  1


 

Abstract
PDF of this Article

Metabolic Syndrome:
Relevance to Psychiatry

Afzal Javed1, Maryam Afzal2

ABSTRACT

The treatment of mental illnesses is receiving considerable attention in the current medical literature and has been a focus of reviews for adapting a holistic approach for recognition and management of the physical health needs of these patients. Metabolic syndrome, a major public health problem linked to cardiovascular and other morbidities, has gained a significant importance in clinical settings and patients with severe mental illnesses who are at higher risk for different components of this syndrome due to their illness and its treatment require careful and regular monitoring in this regard. This article summarises the current thinking about the concept, nature and extent of this syndrome with special reference to mental health and discusses its relevance in the current management of these disorders.

KEY WORDS: Mental disorders, Metabolic syndrome, Antipsychotic drugs, Lifestyle management.

Pak J Med Sci    January - March 2008    Vol. 24 No. 1    181-186


1. Dr. Afzal Javed, M.C.P.S; D.Psych. (Lond.);
Board Cert. Psych, (U.K); M.Phil. F.R.C.Psych.
Consultant Psychiatrist and
Honorary Clinical Associate Professor,
Health Science Research Institute,
Warwick Medical School,
University of Warwick, UK.
2. Dr. Maryam Afzal MBChB (Edin)
Foundation Year,
St John Hospital Livingstone, United Kingdom.

Correspondence

Dr. Afzal Javed
The Medical Centre, 2-Manor Court Avenue,
Nuneaton , CV11 5HX, United Kingdom.
E-mail: afzal.javed@ntlworld.com

* Received for Publication: November 22, 2007

* Accepted: January 8, 2008


Metabolic syndrome is assuming a paramount importance in clinical medicine. Its relevance to cardiovascular diseases and many other illnesses is getting a lot of attention in current medical literature.1 Metabolic syndrome has also been referred as "Syndrome X" and "Insulin Resistance Syndrome" and various definitions have been proposed for this disorder.2 In general this syndrome is conceptualised as a major public health problem that identifies individuals who are at risk for developing diabetes mellitus and / or cardiovascular diseases and can be used as a starting point for clinical interventions known to reduce such risks.3

Competing definitions: There are two competing definitions of metabolic syndrome that are generally referred in the current medical writings. The first one is known as Adult Treatment Panel-III (ATP 111) or NECP criteria (Third report of the National Cholesterol Education Programme Expert Panel on Detection, Evaluation and Treatment of high blood cholesterol in adults) and the other one comes from WHO and is commonly abbreviated as WHO criteria.4,5 Both definitions include criteria relating to the risk factors of abdominal obesity, hypertriglycerdaemia, low HDL-cholesterol and hypertension but WHO definition also mandates the presence of abnormal glucose regulation and microalbuminurea as additional factors. Other definitions also exist, including American Association of Clinical Endocrinologists (AACE) and from the European Group for the study of Insulin Resistance (EGIR).6 Studies using all these definitions may show some variations in their results but it is generally agreed that metabolic syndrome describes a cluster of cardiovascular risk factors and metabolic abnormalities that include abdominal obesity, hypertriglyceridaemia, low HDL-cholesterol, hypertension and abnormal fasting glucose.7

Essential features: Looking at the essential features of metabolic syndrome (abdominal obesity, hypertriglycerdaemia, low HDL-cholesterol and hypertension), current epidemiological data vary in their prevalence in different studies but the rates approximately range from 20-30% in majority of these studies. These figures increase as age advances and similarly different rates are reported for different gender, race and ethnicity.8-10 The National Health & Nutrition Examination Survey III, which was conducted among 8814 US adults aged at least 20 years, demonstrated that the percentage of individuals with at least one metabolic abnormality was 71%, at least two was 44% and at least three (meeting criteria for metabolic syndrome) was 24%. Nearly, 10% of individuals had at least four metabolic abnormalities and 3-5% had all components of the metabolic syndrome.11 Ethnicity is also emerging as an important risk factor in the development of metabolic syndrome and a recent study in UK found that South Asians, living in the UK have a higher prevalence of diabetes, coronary heart disease and cardiovascular deaths with a three to fourfold increase as compared to the local white population.12

While recent reports are showing an increase of this syndrome among general population, a growing concern is being expressed about this problem among mentally ill as well.13 It is an agreed fact that chronic mentally ill are more vulnerable for physical health problems and they show significant increase in relation to their physical health as compared to the general population.14,15 If we look at the risk factors contributing to the high prevalence of medical health problems in mentally ill, the presence of Metabolic Syndrome emerges as an important risk factor for Cardiovascular and Diabetic morbidity. It is generally estimated that Metabolic Syndrome is especially common in patients with Severe Mental Illnesses (SMI) with high prevalence in the range of 30-60% for schizophrenic and bipolar disorders.16-19 The high prevalence of obesity, sedentary lifestyle, smoking and poor diet contributes further to physical morbidity among this group of patients.20 Among the natural causes of death in severely mentally ill, cardiovascular & respiratory diseases are again at the top. Schizophrenics, in particular, die at least 10 years earlier than age matched contemporaries & have an increased relative risk of premature death by two to four fold. A number of studies looking at this association confirm a greater risk of developing metabolic syndrome in the mentally ill as compared to the general population and may explain the increased risk of death in this group of patients due to cardiovascular diseases. Newman & Bland’s study from Canada has shown that 20% of the 301 deaths among 3623 schizophrenic patients were attributed to cardiovascular diseases, resulting in Standarized Mortality Ratio (SMR) of 1.4.21 Similarly, among 307 patients with schizophrenia from a UK study, cardiovascular diseases resulted in 18% of the 79 deaths with a SMR of 1.9.22

The link between various mental illnesses and different components of metabolic syndrome are also getting clearer. Consistent reports suggest that people with schizophrenia are at an increased risk for the development of diabetes mellitus particularly type 2 diabetes mellitus, with a prevalence rate of between 15% and 20%.23,24 These observations clearly echo what Henry Maudsley said in year 1879 that diabetes is a disease which often shows itself in families in which insanity prevails and was also endorsed by Raphael in 1921.25,26 It is true that most mentally ill with diabetes have traditional diabetes risk factors like family history, physical inactivity and dietary variations but abnormalities in glucose and insulin resistance also seem common in many patients. The recent literature is again consistent about the prevalence rate of diabetics ie. around 15% in population with schizophrenia, which represents a two to threefold increase in risk compared to the general population.23,24,27 Based on these findings, the Canadian Diabetic Association in 2003 gave schizophrenia the status of an independent risk factor for Diabetes.28

The clinical manifestations of increased lipid profiles are also among the main causes of morbidity and mortality for cardiovascular diseases and increase in serum cholesterol is considered as a major risk factor for such diseases.29 The main lipids present in serum are cholesterol & triglycerides and their measurement is therefore essential in individuals who are vulnerable for cardiovascular diseases or type 2 diabetes.30,31 Elevated levels of lipids may be attributed to a combination of life style, genetic & many other factors but evidence is accumulating that lipid values above the optimal maximum are observed in many patients who suffer from severe mental illnesses. In terms of lipids profiles in mentally ill, although there is a paucity of data, but there are reports available that shows an increased prevalence of elevated lipid levels or at least the same extent as in the most vulnerable general population. The recent Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study that involved a large sample of schizophrenic patients showed that 64% of subjects met criteria for hyperlipidemia.32 Similarly a Finish study reported that individuals treated with antipsychotic medications were three times more likely to have high cholesterol or high triglyceride than those who were not taking these drugs.33

Side effects of antipsychotic drugs: Antipsychotic drugs control the symptoms of psychiatric illnesses very effectively but there is a growing concern about some of their side effects that contribute to the excess physical morbidity among patients taking these drugs.34,35 This is true for both atypical and typical antipsychotics and looking at different side effect profiles of these drugs, metabolic syndrome again emerges as an important adverse reaction that requires urgent attention of the clinicians.36 Current reports may vary about the differences among second generation antipsychotics (atypicals) drugs for contributing to the different components of Metabolic Syndrome but there is a consensus that this syndrome is emerging as a major side effect of these drugs. Of all the components of metabolic syndrome, statistically significant difference have been found in prevalence rates for weight gain, obesity, elevated BMI, waist circumference & triglycerides and HDL-cholesterol levels among the patients taking these drugs as compared to the general population.37

Diabetes and severe mental illness: Although the association between diabetes and severe mental illnesses are manifolds, a number of publications have mentioned the potential relationship between antipsychotic drugs and hyperglycemia.38-42 The findings that first episode and drug naive patients may show insulin resistance complicates the underlying mechanisms in this regard.43 Worsening of glucose control may not be explained exclusively on the individual drugs itself but the contribution of these drugs for other components of metabolic syndrome including cardiovascular risks and dyslipidaemia certainly contribute to such predisposition.44

Weight gain is an established side effect of most of the antipsychotic drugs (including typical and atypical antipsychotics). This association is well documented for the first generation typical antipsychotics (as for back as 1960) and more recently same association has been described for the newer or second generation atypical antipsychotic drugs.45-47 Many underlying mechanisms operate in weight gain after intake of these drugs. Genetic variation may also play a role48 and though the underlying mechanism remains uncertain, most of these drugs increase weight primarily by increasing caloric intake leading to an increase in adiposity. Excessive weight gain has many adverse clinical consequences including predisposition to a number of physical illnesses like cardiovascular disorders, diabetes, stroke, osteoarthritis and sleep apnoea in addition to low self esteem, decreased quality of life and reduced adherence to treatment. The weight changes has been associated with almost all antipsychotic drugs & this has been consistently observed in clinical experiences both in naturalistic studies as well as in short term & long term Randomized Control Trials (RCTs).45-47 Although current clinical trials and evidence point towards an increase in weight after use of all the typical and atypical antipsychotics but among the atypicals mean weight gain is greatest with Olanzapine and Clozapine and least with Aripeprazole and Ziprasidone.49-51 This has important clinical implications in that it exposes these patients to the risk associated with weight gain such as obesity, hypertension, coronary heart disease and many other physical problems. It is important to know that mentally ill are already at risk with higher standarised mortality rate and this particular side effect of the prescribed medication certainly pose more disadvantages. It is still unclear whether antipsychotics affect glucose metabolisim directly or increase the weight by insulin resistance or work through social disadvantages or some another mechanism.50 Given the growing epidemic of obesity and its consequences, the weight changes in the mentally ill taking antipsychotic medication however remains increasingly relevant.

Antipsychotic medication and adverse lipid levels: Similarly the links between antipsychotic medication and adverse lipid levels is also worth noting. During the last few decades, reports did appear in the medical literature showing an increase in cholesterol and triglycerides in patients taking typical antipsychotics.52 A number of reports have also shown the comparative effects of atypical antipsychotics on lipid levels and current reports53-55 showing links between atypical antipsychotic medication & impaired glucose tolerance and changes in lipids profiles strengthen these views. But one should not forget that poor diet, lack of exercise and increased body weight that are common in mentally ill, are all major predisposing factors for these changes. Similarly majority of these studies are short term and regular monitoring of lipids is not taking place routinely at many centres. But despite these methodological shortcomings in these studies, the concern continues to be of high magnitude.56

SUMMARY

In summary, the current trends in psychiatry and mental health are proposing a comprehensive and holistic approach to the understanding of mental illnesses & their treatment. There is a growing evidence that severe mental illnesses are associated with significant physical co-morbidities57-59 that lead to increased risk of premature mortality in many psychiatric patients.60-63 The challenges in advancing mental health are therefore linked to the physical well being of these individuals and better understanding and more awareness about physical needs of these patients are advocated in the current literature.64,65 Unfortunately physical illnesses are generally overlooked in many patients. Lack of routine physical examinations in psychiatric settings is well known66 but limited awareness among the clinicians about causative & contributing factors leading to adversities in physical health among these patients are also equally important. The need of the time is that mental illnesses are to be integrated into a holistic and comprehensive care system that should also address physical aspects of these illnesses with special reference to their treatment and prevention.67

Metabolic syndrome, a cluster of factors including obesity, hypertriglycedaemia, low HDL-cholesterol, hypertension and abnormal glucose levels, is highly prevalent in mentally ill and adds to further complications and adverse outcomes in these illnesses. This syndrome is considered as an important public health construct that is designed to identify individuals at risk for CVD and / or Diabetes. It is an important condition that has gained worldwide recognition for clinical interventions aimed at reducing these risks as the consequences of this syndrome often include reduced quality of life as well as reduced life expectancy. Its incidence & prevalence are increasing over time in general population but patients with mental illnesses are more prone to developing metabolic disorder than others due to the causes in the illness as well as the side effects of antipsychotic drugs. It is true that antipsychotic medication will continue as an essential treatment strategy for the well being of mentally ill but there is a need to look at the side effects of these drugs and their potential & detrimental effects on physical health as well.68

There is also a need for doing more research about health promotion, quality of life, life style guidance and dietary advice for this group of patients. During the last few decades enough evidence has emerged for predisposition of the severely mentally ill for unhealthy life style that leads to physical inactivity, smoking, drug & alcohol use, weight gain, obesity, cardiovascular diseases and many other health hazards.69 This of course sets an agenda for future action and requires ongoing reviews in pharmacological & non pharmacological interventions for mental illnesses.

A number of guidelines have been proposed looking at effective pharmacological treatment of different mental illnesses, making choices for appropriate drugs and advice about physical healthcare and life style managements for the mentally ill.70,71 Keeping in view the importance of Metabolic Syndrome and related physical health problems, it is expected that clinicians will focus more attention to its diagnosis, treatment and prevention and will also give due consideration to the current drug treatment guidelines in this area. The need to provide some form of management in improving the life style for these patients is also universally accepted & the current evidence does provide clear guidelines and directions for more awareness for programmes needed to promote and support physical well being of the patients with severe mental illnesses.72,73 This is certainly a way forward for the mentally ill who are at higher risk for these problems or many reasons and require a holistic approach for the treatment of their illnesses.

It is hoped that the awareness of different aspects of mental health care and integration of physical healthcare into everyday practice will ensure better physical and mental well being for these patients and would help them to move forward in getting a better quality of life with their physical needs met.

REFERENCES

1. Citrome L. Metabolic syndrome and cardiovascular disease. J Psychopharmacol Suppl 2005;19(6):84-93.

2. Davidson MB. Metabolic syndrome / insulin resistance syndrome /pre-diabetes: new section in diabetic care. Diabetes Care 2003;26:3179.

3. Ford ES, Giles WH, Mokdad AH. Increasing prevalence of the metabolic syndrome among US adults. Diabetic Care 2004;27:2444-9.

4. National Cholesterol Education Programme (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third report of NCEP. JAMA 2001;2486-97.

5. Bloomgarden ZT. Definition of insulin resistance syndrome: the 1st World Congress on the Insulin resistance syndrome. Diabetes Care 2004;27:824-30.

6. American Diabetic Association: American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and diabetes. Diabetes Care 2004; 27: 596-601

7. Ford ES, Giles WH. A comparison of the prevalence of the metabolic syndrome using two proposed definitions. Diabetic Care 2003;26:575-81.

8. Lakha HM, Leaksonen DE, Lakka TA, Niskanen, LK, Kumppusalo E, Tuomilehto J, et al. The metabolic syndrome and total cardiovascular disease mortality in middle aged man. JAMA 2002;288:2709-16.

9. Katzmaryzyk PT. The Canadian obesity epidemic, 1985 – 1998. CMAJ 2002; 166: 1039 -40

10. Kanauchi M, Kanauchi K, Hashimoto T, Saito Y. Metabolic syndrome and new category "pre-hypertension" in a Japanese population. Curr Med Res Opin 2004;20:1365-70.

11. St-Onge MP, Janssen I, Heymsfield SB. Metabolic syndrome in normal weight Americans: New definition of the metabolically obese, normal-weight individual. Diabetes Care 2004;27:2222-8.

12. Mukhopadhyay B, Sattar N, Fisher M. Diabetes and cardiac disease in South Asians. Br J Diabetes Vas Dis 2005;5:253-9.

13. Citrome L, Blonde l, Damatarca C. Metabolic issues in patients with severe mental illness. Southern Med J 2005;98:714-20.

14. Phelan M, Stradins L, Morrisons S. Physical health of people with severe mental illness. BMJ 2001;322:443-4.

15. Ohlsen R, Peacock G, Smith S, Pilowsky I. Assessing physical health in an urban population of people with serious mental illness. Schizophr Bull 2005;21:S567.

16. Thakore JH. Metabolic syndrome and schizophrenia. Br J Psychiatry 2005;186:455-6.

17. Kessing LV, Nilsson FM, Siersma V, Anderson PK. Increased risk of developing diabetes in depressive and bipolar disorders. J Psych Res 2004;38:395-402.

18. Basu R, Brar JS, Chengappa KN, John V, Parepally H, Gershon S, et al. The prevalence of metabolic syndrome in patients with schizoaffective disorders- bipolar subtype. Bipoalr Dosrd 2004;6:314-18.

19. Ryan MCM, Thakore, JH. Physical cosequences of schizophrenia and its treatment: the metabolic syndrome. Life Sci 2002;71:239-57.

20. McCreadie RG. Scotish Lifestyle Group Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry 2003;183:534-9.

21. Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry 1991;36:239-45.

22. Brown S, Inskip H, Barraaclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000;177:212-17.

23. Kohen D. Diabetes Mellitus and schizophrenia: historical perspective. Br J Psychiatry Suppl. 2004;184:S64-6.

24. Expert consensus meeting "Schizophrenia and diabetes 2003, Dublin, 3-4 October: Consensus summary. Br J Psychiatry Suppl 2004;47:S112-14.

25. Maudsley H. The pathology of mind (3rd edition) 1879. Macmillan, London.

26. Raphael T. Blood sugar studies in demential praecox and manic depressive insanity. Arch Neur Psychiatry 1921;5:687-709.

27. Susce MT Villanueva N, Diaz FJ, de Leon J. Obesity and associated complications in patients with severe mental illnesses: a crosssectional survey. J Clin Psychiatry 2005;66:167-73.

28. Canadian Diabetic Association Clinical Practice Guidelines Expert Committee. CDA Clinical Practice Guidelines for the prevention and management of Diabetes: screening and prevention. Canadian J Diabetes Suppl 2003;27:S10-S33.

29. Austin MA, Hokansen JE, Edwards Kl. Hypertriglyceridemia as a cardiovascular risk factor. Am J Cardiol 1998;81:7B-12B.

30. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemic of obesity and diabetes in the United States. JAMA 2001;286:1195-1200.

31. Durrington P. Dyslipidaemia. Lancet 2003;362:717-31.

32. Stroup TS, McEvoy JP, Swartz MS, Byerly MJ, Glick ID, Canive, JM, et al. The National Institute of Mental Health Clinical antipsychotic Trials of Intervention Effectiveness (CATIE) project: Schizophrenia trials design a protocol development. Schizophrenia Bulletin 2003;29:15-31.

33. Saari K, Koponen H, Laitinen J, Jokelainen J, Lauren L, Isohanni M, et al. Hyperlipidaemia in persons using antipsychotic medication: A general population based birth cohort study. J Clin Psychiatry 2004;65:547-50.

34. Davis JM, Chen N, Glick ID. A Meta analysis of the efficacy of second generation antipsychotics. Arch Gen Psychiatry 2003;60:553-64.

35. O’Brien P, Oyebode F. Psychotropic medication and the heart. Advances in Psychiatric Treatment 2003;9:414-23.

36. Lindenmayer JP. Changes in glucose and cholesterol levels in patients with schizophrenia treated with typical and atypical antipsychotics. Am J Psychiatry 2003;160:290-6.

37. Zhang ZJ, Yao ZL, Liu W, Fang Q, Reynolds GP. Effects of antipsychotics on fat deposition and changes in leptin and insulin levels. MRI study of previously untreated people with schizophrenia. Br J Psychiatry 2004;184:58-62.

38. Sernyak M, Leslie D, Alarcan R, Losonczy M, Rosenheck R. Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia. Am J Psychiatry 2002;159:561-6.

39. Dinan TG (ed). Schizophrenia and diabetes 2003: an expert meeting. Br J Psychiatry Suppl 2004;47:S53-S54.

40. Citrome LL. Antipsychotic medication and diabetes mellitus. J Clin Psychiatry 2005;66:395-7.

41. Tighe S, Dinan T. An overview of the central control of weight regulation and the effect of antipsychotic medication. J Psychopharm Suppl 2005;19(6):36-46.

42. Taylor D, Young C, Mohamed R, Paton C, Walwyn R. Undiagnosed impaired fasting glucose and diabetes mellitus amongst inpatients receiving antipsychotic drugs. J Psychopharmacol 2005;19:182-6.

43. Ryan MC, Collins P, Thakore JH. Impaired fasting glucose tolerance in first episode, drug naïve patients with schizophrenia. Am J Psychiatry 2003;160:284-9.

44. Jin H, Meyer JM, Jeste DV. Atypical antipsychotics and glucose dysregulation: A systematic review. Schizphr Res 2004;71:195-212.

45. Klett C, Caffey E. Weight changes in relation to the characteristics of patients on chlorpromazine. J Neuropsychiatry 1960;2:102-8.

46. Wirshing DA, Wirshing WC, Kysar l, Bersiford MA, Goldstein D, Pashag J. Noval antipsychotics; comparison of weight gain liabilities. J Clin Psychiatry 1999;60:358-63.

47. Taylor DM, McAskill R. Atypical antipsychotics & weight gain–A systematic review. Acta Psychiatr Scand 2000;101:416-32.

48. Gough SC, O’Donovan MC. Clustring of metabolic comorbidity in schizophrenia: A genetic contribution? J Psychopharm Suppl 2005;19:6:47-55.

49. McIntyre RS, Trakas K, Lin D, Balshaw R, Hwang P, Robinson K, et al. Risk of weight gain associated with antipsychotic treatment: Results from the Canadian National Outcome Measurement Study in Schizophrenia. Can J Psychiatry 2003;48(10):689-94.

50. Bushe C, Leonard B. Association between atypical antipsychotic agents and type 2 diabetes: review of prospective clinical data. Br J Psychiatry Suppl 2004;47:S87-S93.

51. Smith RC, Lindenmayer JP, Bark N, Warner-Cohen J, Vaidhyanathaswamy SK. Clozapinr, Rieperidone, Olanzapine and conventional antipsychotic drug effects on glucose, lipids and leptons in schizophrenic patients. Int J Neuropsychopharmacol 2005;8:183-94.

52. Shafique M, Khan IA, Akhtar MH, Hussain I. Serum lipids and lipoproteins in schizophrenic patients receiving major tranquilizers. J Pak Med Assoc 1988;38:259-61.

53. Meyer JM. Effects of atypical antipsychotics on weight and serum lipid levels. J Clin Psychiatry Suppl 2001;27:27-34.

54. Meyer JM, Kore CE. The effects of antipsychotics therapy on serum lipids: a comprehensive review. Schizophr Res 2004;70:1-17.

55. Paton C. Esop R, Young C, Taylor D. Obesity, dyslipidaemias and smoking in an inpatient population treated with antipsychotic drugs. Acta Psychiatr Scand 2004;110:299-305.

56. Lambert BL, Chang KY, Tafasse E, Carson W. Association between antipsychotic treatment and hyperlipdaemia among Califonia Medicaid patients with schizophrenia. J Clin Pychopharmacology 2005;25:12-8.

57. Davidson S, Judd F, Jolley D, Hocking B, Thompson S, Hyland B. Cardiovascular risk factors for people with mental illness. Aust N Z J Psychiatry 2001;35:196-202.

58. Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005;150(6):1115-21.

59. Mitchell AJ, Malone D. Physical health and schizophrenia. Curr Opin Psychiatry 2006;19(4):432-7.

60. Dembling BP, Chen DT, Vachon L. Life expectancy and causes of death in a population treated for serious mental illness. Psychiatr Serv 1999;50(8):1036-42.

61. Lawrence D, Jablensky AV, Holman CDJ, Pinder TJ. Mortality in Western Australian psychiatric patients. Soc Psychiatry Psychiatr Epidemiol 2000;35(8):341-7.

62. Kurihara T, Kato M, Kashima H, Takebayashi T, Reverger R, Tirta IGR. Excess mortality of schizophrenia in the developing country of Bali. Schizophr Res. 2006;83(1):103-5.

63. Saha S, Chant D, McGrath J. A Systematic Review of Mortality in Schizophrenia. Is the Differential Mortality Gap Worsening Over Time? Arch Gen Psychiatry 2007;64(10):1123-31.

64. Druss BG, Bradford WD, Rosenheck RA. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001;58:565 -72.

65. Marder SR, Essock SM, Miller AL, Buchanan RW, Casey DE, Davis JM, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004;161(8):1334-49.

66. Coghlan R, Lawrence D, Jablensky A. Duty to Care: Physical Illness in People with Mental Illness. Perth: The University of Western Australia; 2001.

67. Byng R. Physical care for patients with mental illness. Practitioner 2004;248:440-5.

68. Remington G. Schizophrenia, antipsychotics, and the metabolic syndrome: is there a silver lining? Am J Psychiatry 2006;163(7):1132-4.

69. Brown S, Birtwistle J, Roe l, Thompson C. The unhealthy lifestyle of people with schizophrenia. Psychol Med 1999;29:697-701.

70. National Institute for Clinical Excellence (NICE) Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia. Techanology Appraisal Guidance No 43. 2002; London Available at:http;//www.nice.org.uk

71. Lehman AF, Lieberman JA, Dixon LB, McGlashan TH, Miller AL, Perkins DO, et al. American Psychiatric Association, steering committee on practice guidelines for the treatment of patients with schizophrenia. Am J Psychiatry Sppl 2004;161:1-56.

72. Lloyd C, Sullivan D. NEW solutions: an Australian health promotion programme for people with mental illness. Int J Therapy Rehab 2003;10(5):204-10.

73. Ganguli R, Brar JS. Prevention of weight gain by behavioral interventions in patients starting on noval antipsychotics. Schizophr Bull 2005;21:S561.


HOME   |   SEARCH   |   CURRENT ISSUE   |   PAST ISSUES

Professional Medical Publications
Room No. 522, 5th Floor, Panorama Centre
Building No. 2, P.O. Box 8766, Saddar, Karachi - Pakistan.
Phones : 5688791, 5689285 Fax : 5689860
pjms@pjms.com.pk