It is widely reported that patients with schizophrenia are at increased risk of poor physical health and are dying 20 years earlier than the general population (see People with schizophrenia are significantly more likely to die from heart disease and cancer and National Schizophrenia Audit calls for improved monitoring of physical health in people with schizophrenia). A number of factors may influence this: stigma, poorer access to healthcare, diagnostic overshadowing, lifestyle factors and the adverse effects of psychotropic medications.
This paper by Correll and colleagues (Correll et al, 2015) aims to summarise physical health risks associated with various drug treatments (antipsychotics, antidepressants and mood stabilisers) for people with schizophrenia, depression and bipolar disorder.
This is an update of a previous systematic review published in 2011. An additional search of MESH terms was conducted via Medline from 2009 to 2014, restricted to English language only. The researchers aimed to include only systematic reviews or meta-analysis, although did include individual studies for some diseases. There was no discussion of critical appraisal or selection techniques for studies identified. The search identified 13,477 hits which appears to include 2,429 reviews.
- The risk for weight gain is greatest in the early weeks of treatment, and is greater for second generation antipsychotics (i.e. clozapine, olanzapine). Antidepressants, mood stabilisers and some first generation antipsychotics can also contribute to weight gain.
- The risk for diabetes mellitus (type 2) is greater in those with schizophrenia and bipolar disorder and seems to be linked to antipsychotic treatment. This may or may not be linked to weight gain. There seems to be some risk of developing diabetes associated with mood stabilisers and antidepressants although this is less clear.
- The risk for coronary heart disease and stroke are clearly higher in people with schizophrenia, but how antipsychotic treatment influences this is less well understood. Whilst antidepressants (particularly tricyclics) risks are clearly known about, the role of mood stabilisers is less well understood.
- The risk of sudden cardiac death is higher for those treated with antipsychotic and antidepressant medications; this appears to be dose related. The importance of ECG (electrocardiogram) monitoring is therefore essential to identify changes to heart rates and beats.
- The risk of pneumonia appears greatest when treated with clozapine (for both treatment in schizophrenia and bipolar disorder) and second generation antipsychotics. On their own, antidepressants and mood stabilisers appear to have no significant risk.
- The risk of leukocytopenia/ neutropenia (fewer of these white blood cells) and agranulocytosis (impact on immunity) is associated with antipsychotics, mood stabilisers and antidepressants. The greatest risk is associated with starting treatment with clozapine particularly for neutropenia and agranulocytosis.
- The risk of reduced bone density, osteoporosis and broken bones is higher in schizophrenia and bipolar disorders. This seems related to antipsychotics and newer antidepressants (SSRIs).
- Antidepressants and antipsychotics can reduce the seizure threshold. First generation antipsychotics are more likely to lead to movement disorders. Lithium particularly after long-term use might lead to reduced renal function.
The authors concluded:
In general, adverse effects on physical health are greatest with antipsychotics, followed by mood stabilisers, tricyclic antidepressants and newer antidepressants. However, effects vary greatly among individual agents, and interactions with underlying host factors are relevant. Higher dosages, polypharmacy, and the treatment of vulnerable (e.g. old or young) people seems to be associated with a greater effect on most physical diseases.
The search was limited to English language only, and focused on MeSH terms. There was no discussion of the quality of literature included. It was not clear how the literature was synthesised together and how risk judgements were made. There is also no account of how or if the previous systematic review was integrated into this newer one.
Overall this made for a rather frustrating read and it was difficult to critically appraise this review because the methods section was very brief. Of course this may simply be that the journal (World Psychiatry) did not have sufficient space to publish a lengthy methods section, in which case I invite the study authors to contact us and share their methods more fully, e.g.
- How many and what type of studies were included in your analysis?
- What inclusion criteria did you use?
- Who was involved in selecting studies for inclusion?
- How was study quality assessed?
- How was the data synthesised?
- How were risk judgements made?
Whilst psychotropic medication can help with symptoms, contribute to recovery and reduce risks such as suicide, it can clearly impact negatively on the physical health and well-being of the patient. In addition to the iatrogenic effects of psychotropic medication the health service needs to work harder at ensuring that individuals with mental health disorders have and maintain good physical health. Lia Ali’s blog and the IMPARTS team work are good example of recent initiatives to do this.
It’s incredibly important, but incredibly difficult to synthesise and summarise the vast literature on the impact of treatments for mental health disorders (antipsychotics, antidepressants and mood stabilisers) has on aspects of physical health. If nothing else I would recommend spending time exploring Table 2 of the Correll (2015) paper which provides a good summary of all of their findings across the conditions and associated treatments. Clearly the focus of future research needs to be on those physical health conditions which have been less well explored or studied for example, sudden death, sexual and reproductive health, impact on hormones and conditions which may result from this.
Correll CU, Detraux J, De Lepeleire J, De Hert M. (2015) Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder (PDF). World Psychiatry. 2015 Jun;14(2):119-36. doi: 10.1002/wps.20204.
DE Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Möller HJ, Ndetei DM, Newcomer JW, Uwakwe R, Leucht S. (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care (PDF). World Psychiatry. 2011 Feb;10(1):52-77.
What impact are psychotropic drugs having on our physical health? http://t.co/HHITAtX9xA #MentalHealth http://t.co/jJq5FdBi9a
Potentially important review: the impact of medication on physical health BUT the methodology is unclear @Mental_Elf https://t.co/sOfsEqdYpE
Not about #pillshaming but #pillknowing, physical effects of mental health drugs, part of risk/benefit discussion http://t.co/h9ZOW6pZ4M
I went to study from 4-2013 to 9-2014, I returned to Vietnam. Then 5-2015 I went to a mental health department diagnosed with depression. I took risperidone and Sertraline from 5-2015 until now. But by 10-2016, I had a disc herniation and had to treat this disease further. I am concerned about the effects, effects and side effects of risperidone and Sertraline on the risk of musculoskeletal disease especially my disc herniation. In order to really find its effect, it is expected to get the treatment regimen for both to be effective. Please give me advice or have research materials on this issue.
“What impact do psychotropic drugs have on physical health?” Mental Elf http://t.co/VNU38FXr4c
What impact do psychotropic drugs have on physical health? http://t.co/yUXXTtGoTk
What impact are psychotropic drugs having on our physical health? https://t.co/SknmbfqLLp via @sharethis
What impact are psychotropic drugs having on our physical health? http://t.co/z5bM0erJSX via @theoldreader
All drugs have effects & side effects, my @Mental_Elf blog explores the physical effects of mental health drugs
Paper examines the health effects of psychotropic drugs. Antipsychotics and mood stabilizers are the worst.
#Antipsychotics, #Antidepressants, #MoodStabilisers – adverse effects on #PhysicalHealth http://t.co/iRNizqmbIw New from @JohnBaker_Leeds
@Mental_Elf it’s a hard balance. Meds literally keep ppl alive but they feed a ? of depression: meds – weight gain – depression (1/2)
@Mental_Elf (2/2) more meds – diabetes/thyroid probs – more meds and on and on. Never mind the initial gruelling side effects
¿Qué impacto tiene la medicación psicotrópica sobre nuestra salud física? http://t.co/VydynmjVH8 spoiler: importante
RT @Mental_Elf: Don’t miss: What impact are psychotropic drugs having on our physical health? http://t.co/iRNizqmbIw #EBP
What impact are psychotropic drugs having on our physical health? https://t.co/g3qpNxPjrh via @sharethis interesting!
What impact are psychotropic drugs having on people’s physical health? http://t.co/pOm3piR9d7
What impact do psychotropic drugs have on physical health? http://t.co/BNGoA6ac0h via @Instapaper
What impact are psychotropic drugs having on our physical health? https://t.co/x1EkvM19xW via @sharethis
Hi looking at the data justifying ECGs.
The data around sudden cardiac death (SCD) in the paper suggest a risk of 3.4/1000 years. the earlier paper you referenced suggests an increased risk of just 3 times for antpispychotics
This suggests an approximate absolute increased risk of about 2/1000 patient years
This risk is presumably higher in those drugs with a larger effect on SCD e.g. sertindole etc
This suggests to me that ECGs (which only show you are in a higher risk group for SCD not that you will definitely get SCD) are possibly only indicated if you have a suggestive cardiac history or are on an drug with a higher risk of QTc prolongation. It would also be prudent to check an ECG in inpatients who’ve never had an antipsychotic before.
Recommending routinely an investigation for a very small absolute risk which is not highly predictive of the outcome isn’t always the best thing to do
What impact are #psychotropic drugs having on our physical health? http://t.co/7BKopOGJU8 @Mental_Elf looks at a #systematicreview
Is it important to distinguish between the side effects ‘weight gain’ and ‘increased appetite’? The former suggests metabolic changes causing weight gain, independent of the latter which can include cravings for particular food and drink (often high in sugar and/or fat). Distinguishing between the 2 terms leads to different approaches, interventions and lifestyle choices for people.
From personal experience #mood stablizers destablize blood sugar..goes straight to storage!