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Background and Hypothesis: Previous studies show that people with severe mental illness (SMI) are at higher risk of COVID-19 mortality, however limited evidence exists regarding risk post-vaccination. We investigated COVID-19 mortality among people with schizophrenia and other SMIs before, during and after the UK vaccine roll-out., Study Design: Using the Greater Manchester (GM) Care Record to access routinely collected health data linked with death records, we plotted COVID-19 mortality rates over time in GM residents with schizophrenia/psychosis, bipolar disorder (BD) and/or recurrent major depressive disorder (MDD) from February 2020 to September 2021. Multivariable logistic regression was used to compare mortality risk (risk ratios; RRs) between people with SMI (N=190,188) and age-sex matched controls (N=760,752), adjusted for sociodemographic factors, pre-existing comorbidities and vaccination status., Study Results: Mortality risks were significantly higher among people with SMI compared with matched controls, particularly among people with schizophrenia/psychosis (RR 3.14, CI 2.66-3.71) and/or BD (RR 3.17, CI 2.15-4.67). In adjusted models, the relative risk of COVID-19 mortality decreased, though remained significantly higher than matched controls for people with schizophrenia (RR 1.53, CI 1.24-1.88) and BD (RR 2.28, CI 1.49-3.49), but not recurrent MDD (RR 0.92, CI 0.78-1.09). People with SMI continued to show higher mortality rate ratios relative to controls throughout 2021, during vaccination roll-out., Conclusions: People with SMI, notably schizophrenia and bipolar disorder, were at greater risk of COVID-19 mortality compared to matched controls. Despite population vaccination efforts that have prioritised people with SMI, disparities still remain in COVID-19 mortality for people with SMI., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background and Hypothesis Previous studies show that people with severe mental illness (SMI) are at higher risk of COVID-19 mortality, however limited evidence exists regarding risk postvaccination. We investigated COVID-19 mortality among people with schizophrenia and other SMIs before, during and after the UK vaccine roll-out. Study Design Using the Greater Manchester (GM) Care Record to access routinely collected health data linked with death records, we plotted COVID-19 mortality rates over time in GM residents with schizophrenia/psychosis, bipolar disorder (BD), and/or recurrent major depressive disorder (MDD) from February 2020 to September 2021. Multivariable logistic regression was used to compare mortality risk (risk ratios; RRs) between people with SMI (N = 193 435) and age–sex matched controls (N = 773 734), adjusted for sociodemographic factors, preexisting comorbidities, and vaccination status. Study Results Mortality risks were significantly higher among people with SMI compared with matched controls, particularly among people with schizophrenia/psychosis (RR 3.18, CI 2.94–3.44) and/or BD (RR 2.69, CI 2.16–3.34). In adjusted models, the relative risk of COVID-19 mortality decreased, though remained significantly higher than matched controls for people with schizophrenia (RR 1.61, CI 1.45–1.79) and BD (RR 1.92, CI 1.47–2.50), but not recurrent MDD (RR 1.08, CI 0.99–1.17). People with SMI continued to show higher mortality rate ratios relative to controls throughout 2021, during vaccination roll-out. Conclusions People with SMI, notably schizophrenia and BD, were at greater risk of COVID-19 mortality compared to matched controls. Despite population vaccination efforts that have prioritized people with SMI, disparities still remain in COVID-19 mortality for people with SMI.

Background and Hypothesis Gut microbiota alterations have been reported in severe mental illness (SMI) but fewer studies have probed for signs of gut barrier disruption and inflammation. We hypothesized that gut leakage of microbial products due to intestinal inflammation could contribute to systemic inflammasome activation in SMI. Study Design We measured plasma levels of the chemokine CCL25 and soluble mucosal vascular addressin cell adhesion molecule-1 (sMAdCAM-1) as markers of T cell homing, adhesion and inflammation in the gut, lipopolysaccharide binding protein (LBP) and intestinal fatty acid binding protein (I-FABP) as markers of bacterial translocation and gut barrier dysfunction, in a large SMI cohort (n = 567) including schizophrenia (SCZ, n = 389) and affective disorder (AFF, n = 178), relative to healthy controls (HC, n = 418). We assessed associations with plasma IL-18 and IL-18BPa and leukocyte mRNA expression of NLRP3 and NLRC4 as markers of inflammasome activation. Study Results Our main findings were: (1) higher levels of sMAdCAM-1 (P = .002), I-FABP (P = 7.6E−11), CCL25 (P = 9.6E−05) and LBP (P = 2.6E−04) in SMI compared to HC in age, sex, BMI, CRP and freezer storage time adjusted analysis; (2) the highest levels of sMAdCAM-1 and CCL25 (both P = 2.6E−04) were observed in SCZ and I-FABP (P = 2.5E−10) and LBP (3) in AFF; and (3), I-FABP correlated with IL-18BPa levels and LBP correlated with NLRC4. Conclusions Our findings support that intestinal barrier inflammation and dysfunction in SMI could contribute to systemic inflammation through inflammasome activation.

Background Feasible and effective interventions to improve daily functioning in people with a severe mental illness (SMI), such as schizophrenia, in need of longer-term rehabilitation are scarce. Aims We assessed the effectiveness of Cognitive Adaptation Training (CAT), a compensatory intervention to improve daily functioning, modified into a nursing intervention. Method In this cluster randomized controlled trial, 12 nursing teams were randomized to CAT in addition to treatment as usual (CAT; n = 42) or TAU (n = 47). Daily functioning (primary outcome) was assessed every 3 months for 1 year. Additional follow-up assessments were performed for the CAT group in the second year. Secondary outcomes were assessed every 6 months. Data were analyzed using multilevel modeling. Results CAT participants improved significantly on daily functioning, executive functioning, and visual attention after 12 months compared to TAU. Improvements were maintained after 24 months. Improved executive functioning was related to improved daily functioning. Other secondary outcomes (quality of life, empowerment, negative symptoms) showed no significant effects. Conclusions As a nursing intervention, CAT leads to maintained improvements in daily functioning, and may improve executive functioning and visual attention in people with SMI in need of longer-term intensive psychiatric care. Given the paucity of evidence-based interventions in this population, CAT can become a valuable addition to recovery-oriented care.

Objective Obesity and adverse metabolic outcomes in patients with severe mental illness are clinically significant but potentially preventable. Importantly, the evidence for switching to antipsychotics to reduce cardiometabolic burden is unclear. Method PubMED, Embase, PsycINFO, and Cochrane were searched from inception to March 8, 2020. Articles reporting weight and metabolic changes after antipsychotic switching vs staying on the previous antipsychotic were meta-analyzed both across and within group. Results Of 61 identified studies, 59 were meta-analyzed (40% rated high quality). In the switch-vs-stay pairwise meta-analyses, only aripiprazole significantly reduced weight (−5.52 kg, 95% CI −10.63, −0.42, P = .03), while olanzapine significantly increased weight (2.46 kg, 95% CI 0.34, 4.57, P = .02). Switching to aripiprazole also significantly improved fasting glucose (−3.99 mg/dl, 95% CI −7.34, −0.64, P = .02) and triglycerides (−31.03 mg/dl, 95% CI −48.73, −13.34, P = .0001). Dropout and psychosis ratings did not differ between switch and stay groups for aripiprazole and olanzapine. In before-to-after switch meta-analyses, aripiprazole (−1.96 kg, 95% CI −3.07, −0.85, P < .001) and ziprasidone (−2.22 kg, 95% CI −3.84, −0.60, P = .007) were associated with weight loss, whereas olanzapine (2.71 kg, 95% CI 1.87, 3.55, P < .001), and clozapine (2.80 kg, 95% CI 0.26, 5.34, P = .03) were associated with weight gain. No significant weight or other cardiometabolic changes were observed when switching to amisulpride, paliperidone/risperidone, quetiapine, or lurasidone. Conclusions Switching antipsychotics to agents with lower weight gain potential, notably to aripiprazole and ziprasidone, can improve weight profile and other cardiometabolic outcomes. When choosing switch agents, both the weight gain potential of the pre- and post-switch antipsychotic must be considered. Antipsychotic switching in psychiatrically stable patients must be weighed against the risk of psychiatric worsening.

Background The prevalence of obesity is increasing public health problem with significant costs. Elevated risk for obesity is reported in patients with severe mental illness. People with obesity have an increased risk for a number of common medical conditions, including type 2 diabetes, cardiovascular disease, coronary heart disease, dyslipidemia and hypertension. The increased physical illness may be associated with unhealthy lifestyles such as smoking, substance use, often with inadequate access to health services. Still, very is known about the comorbidity of SMI and obesity in families. We explored the association between parental severe mental illness and BMI in middle-aged offspring. Our hypothesis was that offspring of people with severe mental illness have increased risk for obesity. Methods The Northern Finland Birth Cohort 1966 is cohort study of offspring with expected date of birth in 1966. The final study sample included 5,467 middle-aged offspring. We used parental severe mental illness as exposure in the study. BMI measured.at the age of 46 years was classified in for categories: underweight (BMI below 18.5), normal range (BMI 18.5–24.9), overweight (BMI 25.0–29.9), obese class I (BMI 30.0–34.9) and obese class II-III (BMI 35 or more). We used mothers’ marital status, smoking, educational level and offspring’ place of birth as confounders. Results Risk for obesity was elevated in offspring of mothers with SMI (overweight: adjusted OR 1.81 (1.25–2.63), obese class I: 1.71 (1.08–2.73), obese class II-III: 2.36 (1.35–4.13)). For offspring of fathers with SMI the results were not statistically significant (overweight: adjusted OR 0.94 (0.70–1.26), obese class I: 1.42 (1.00–2.00), obese class II-III: 0.89 (0.51–1.56)). Discussion According to our knowledge, this is the first study of BMI in adult offspring of parents with severe mental illness. We found an elevated risk of obesity in the middle-aged offspring of mothers with SMI. The findings support our hypothesis of higher morbidity from obesity in offspring of parents with SMI. We found an elevated risk of substantially increased BMI in the middle-aged offspring of mothers with SMI. However, we did not find elevated risk of increased BMI in the middle-aged offspring of fathers with SMI and when examining the offspring of either parent with SMI. This means that there might be a common familial pathway leading to co-occurrence of obesity and SMI.

Background Individuals with severe mental illness (SMI) may be considered violent, but in most cases they are victims. Substance abuse, a clinical history of violence and gender are among the main risk factors for aggressive behavior. To date, evidence on the mechanisms involved in violent behavior in SMI is still scarce and controversial. From a neuropsychological point of view, the deficits in executive functions, may be a key element in increasing propensity to violence. Methods Sample: 50 offender SMI patients recruited at the Residence for the Execution of Security Measures (REMS) of Castiglione d/S (case group) and 35 non-offender SMI patients recruited at the Department of Mental Health and Addictive Disorders of Brescia (control group). Match 1: 1 by gender, education and main diagnosis. An interview was given to collect the anamnestic data. All patients were assessed with clinical (CGI-S, PANSS-EC), neurocognitive (TMT, SCWT, BACS), social cognitive (FEIT), psychosocial functioning / wellness (MCH-SF, PSP), impulsiveness (BIS-11, IGT) and aggressive behaviour risk assessment (MOAS, HCR-20, PCL-R) measures. Results The two groups appeared to be significantly different as far as the total scores for both HCR-20 and PCL-R, with REMS patients have significant higher values. HCR-20 and PCL-R showed a significant predictive value independent of each other, in determining membership of the case group or control group. In particular, each additional point in the HCR-20 increased the probability of belonging to the case group of 1.8, while each additional point at the PCL-R increased this probability by 1.3. Significant differences were observed regarding the CGI-S and the PANSS-EC scores, where REMS patients had, at the same diagnosis, more severe psychopathology. PANSS-EC, BACS token test and SCWT errors showed a significant independent predictive value in HCR-20 score. In particular, for each additional point at the PANSS-EC, the HCR-20 increased 1 point, while this score is reduced by 0.16 for each additional point to the BACS token test and 0.42 for each additional point to the SCWT errors. Considering the cognitive profile, poorer performances were found in the offenders patients in the TMT-A and the BACS token exercise, indicating greater deficits in both visuomotor speed and attention. Regarding school performance (a possible proxy of cognitive reserve), the two groups appeared significantly different for the number of failures (p Discussion Results of the present study highlight that offenders patients with SMI have higher levels of clinical, cognitive and friends relationships severity, but better social cognition skills and a higher degree of perceived well-being. The greatest number of failures in REMS patients could be due to a greater impairment of cognitive function from an early stage of the disease. Even if the majority of crimes is carried out against the family members, family relationships do not present differences between the two groups. Although preliminary, these results could help clinicians to better understand offenders patients with SMI and to identify more homogeneous subgroups of patients, in order to plan more tailored care pathways.

Background High intensity interval training (HIIT) is a type of exercise involving alternating short bursts of high intensity exercise with recovery periods of rest or light exercise. HIIT has been shown to improve physical and mental health in healthy individuals and those with physical illnesses, such as cardiovascular and cardiometabolic diseases. Initial work has shown that HIIT may have similar benefits in people experiencing mental illnesses. The primary aim for the trial is to investigate whether HIIT is acceptable and feasible amongst inpatients with severe mental illnesses (SMI), including schizophrenia. The secondary aim is to investigate the impact of the HIIT intervention on potential outcome measures for a definitive multi-centre RCT, including mental health symptoms, cognition, psychiatric symptoms and cardio-metabolic risk factors. Methods A randomised, non-blinded controlled design of HIIT compared to treatment as usual (TAU) in inpatients with SMI will be undertaken. The RCT will act as a feasibility trial and a pilot study. Up to forty 18-60-year olds with a diagnosis of SMI will be recruited and randomly allocated to either 12 weeks of HIIT or 12 weeks of TAU in a 1:1 ratio. Those in the HIIT group will take part in two one-to-one sessions of HIIT each week for 12 weeks on a stationary bike. Each session will comprise: a 4-minute warm-up, followed by 5X 60 second intervals with 85–95% of maximum heart rate (HRmax), with active pauses of 90 seconds cycling at approximately 60–70% of HRmax, followed by a 4-minute cool-down, although this will be adapted for those with lower fitness. In comparison, participants allocated to TAU will be provided with details of their local hospital gym availability and instructed to maintain their usual dietary habits. Acceptability and feasibility will be measured using multiple primary endpoints including the proportion of wards that agree to hosting the project, the proportion of people who consent to take part, adherence and attendance rates, and the proportion of participants who experience any adverse events. Multiple secondary endpoints will be assessed including, mental health markers (psychiatric symptoms, cognition, global functioning, sleep quality, depression, anxiety and stress), self-esteem, cardiometabolic markers (BMI, weight, waist circumference, systolic and diastolic blood pressure), daily activity levels, and cigarette usage. Results Primary endpoints will be reported post-trial completion and summarised by treatment arm over the course of the study. Secondary endpoints will be reported as pre-post intervention change, and overall group differences will be reported. For these secondary endpoints, a statistical analysis will be conducted based on the intention-to-treat sample. Additionally, a subgroup analysis will be conducted whereby we will measure secondary outcome effects in a sub-sample of participants with ‘high’ attendance (>64%). Discussion Following the pilot study, if HIIT is considered to be feasible and acceptable amongst inpatients with SMI, including schizophrenia, a further large-scale multi-centre study can be developed and undertaken to assesses the effectiveness of HIIT in ameliorating mental and physical health parameters, and time to discharge, in this population group.

Objective We examined the academic performance at age 12 years of children of mothers diagnosed with schizophrenia or other severe mental illness using a large whole-population birth cohort born in Western Australia. We investigated the association between academic performance and the subsequent development of psychotic illness. Method The sample comprised 3169 children of mothers with severe mental illness (schizophrenia, bipolar disorder, unipolar major depression, delusional disorder or other psychoses; ICD-9 codes 295–298), and 88 353 children of comparison mothers without known psychiatric morbidity. Academic performance of children was indexed on a mandatory state-wide test of reading, spelling, writing and numeracy. Results A larger proportion of children (43.1%) of mothers with severe mental illness performed below the acceptable standard than the reference group (30.3%; children of mothers with no known severe mental illness). After adjusting for covariates, children of mothers with any severe mental illness were more likely than the reference group to perform below-benchmark on all domains except reading. For all children, poor spelling was associated with the later development of psychosis, but particularly for those at familial risk for severe mental illness (hazard ratio [HR] = 1.81; 95% CI for HR = 1.21, 2.72). Conclusions Children of mothers with a severe mental illness are at increased risk for sub-standard academic achievement at age 12 years, placing these children at disadvantage for the transition to secondary school. For children with familial risk for severe mental illness, very poor spelling skills at age 12 years may be an indicator of risk for later psychotic disorder.

Background Consistent evidence suggests that there is an association between childhood trauma and psychotic disorders. Exposure to childhood trauma among people with severe mental illness (SMI) is associated with a range of negative outcomes, including exacerbation of symptoms, higher rates of readmission and relapse, poorer levels of social and vocational functioning, substance use and self-harm (Grubaugh et al., 2011). We aimed to identify people with SMI and a history of CSA as recorded in electronic health records in a large mental healthcare provider in the UK, describe the clinical and functional characteristics these patients and compare their clinical outcomes (admissions, medication) to those of patients with no recorded history of CSA. Methods Data for this study were obtained from Camden & Islington NHS Foundation Trust using the Clinical Record Interactive Search (CRIS) tool. CRIS is an application developed to enable routinely collected electronic health records to be used in research. C&I NHS FT is a large mental health provider serving a geographic catchment area of two inner-city London boroughs, and approximately 470,000 residents. For purposes of this study we identified patients with an ICD-10 diagnosis of F20-F29 or F30-31 with at least one year of follow-up. We searched text records (clinical notes and documents) for keywords associated with CSA, using an iterative process of inclusion and exclusion rules. We then tested the positive predictive value of this search. We compared the demographic, clinical and functional characteristics of patients with and without a history of CSA using chi square tests. Next, we used logistic regression models to examine the outcomes of inpatient admission and receipt of antipsychotic medication among the study population. Results We identified 7,000 patients with SMI, of which 619 (8.8%) hade a recorded history of CSA. Patients with a recorded history of CSA were more likely to be female (63.8% vs. 43.3%), single (76.9% vs. 66.5%), of white ethnic origin (66.4% vs. 54.3%) than their counterparts without CSA. There was no difference in the distribution of social deprivation between the groups. Major depressive disorder, posttraumatic stress disorder and personality disorders were all more prevalent in patients with CSA (13.4% vs. 7.6%, 4.7% vs. 1.4%, and 22.0% vs. 5.8%, respectively). Higher rates of moderate-severe psychotic symptoms, depressed mood, self-harm, substance use and aggression were also evident in this group, as were problems with relationships and accommodation. There was a 2-fold increase in the odds of inpatient admissions in patients with a history of CSA than in those without (adjusted OR=1.95, 95% CI: 1.64–2.33), and they were more likely to have spent at least 10 days a year as inpatients (adjusted OR=1.32, 95% CI: 1.07–1.62). Similarly, patients with a history of CSA were more likely to be prescribed antipsychotic medication (adjusted OR=2.48, 95% CI: 1.69–3.66), and more likely to be given over 75% of the maximum recommended dose (adjusted OR=1.72, 95% CI: 1.44–2.04). Discussion The current study used routinely recorded data from electronic health records to identify a history of childhood sexual abuse in patients with SMI. Consistent with previous findings, the study demonstrated that exposure to childhood trauma is associated with negative clinical and functional outcomes in these patients. Clinicians working with patients with SMI should be trained and skilled at assessing childhood adversity, and addressing such adversity in the clinical setting.

Abstract not included.

BACKGROUND: We adapted an interactive obesity treatment approach (iOTA) derived from the Diabetes Prevention Program, incorporating short message service (SMS) messaging to supplement in-person health coaching. Treatment was delivered in Community Mental Health Center (CMHC) and the Clubhouse settings. Here, we describe the results of the 12-week feasibility test. We hypothesized that illness severity and iOTA engagement would be associated with weight change. METHODS: Treatment Adaptation: Individuals with SMI between the ages of 16 and 75 underwent 12 weeks of treatment consisting of monthly 1:1 in-person visits for participants seen in the CMHC setting and monthly group sessions for participants seen in the Clubhouse setting. All participants received SMS-based health tips 5 days per week that were directly related to their goals. Participants were prompted once a week to respond via text with their weight and progress towards goals. Treatment adaptations included increased frequency of in-person meetings, weekly phone check-ins as needed, and incorporation of evidence-based psychological approaches to address barriers to behavior change (cognitive behavioral therapy, interpersonal therapy and dialectic behavior therapy). Defining Criteria for Illness Severity & Engagement: We evaluated factors hypothesized to be associated with change in weight, including illness severity and treatment engagement. “Severe” psychiatric symptoms were defined as baseline Clinical Global Impression (CGI) Severity score of >5. Criterion engagement was defined as text messaging response rate of >80% over the first 4 weeks of treatment. Disordered eating, assessed with the Loss of Control Over Eating Scores (LOCES), was also evaluated. Analytic Approach: Repeated measures ANCOVA was used to test for the effect of time on weight change, including 2-level factors for membership in included/excluded participant group and treatment setting, as well as an exploratory covariate representing score on the LOCES. Finally, we evaluated whether treatment setting had an effect on weight change over time. Significance was set at p5 and response rate

As Individual Placement and Support (IPS) has become the international standard for vocational rehabilitation of adults with serious mental illness, researchers must consider the relationship between IPS and local environments. This meta-analysis used mixed-effects meta-regressions to assess the impact of site-level moderators on the likelihood that IPS recipients, compared with recipients of alternative vocational services, achieved competitive employment. Potential moderators included change in gross domestic product (GDP), local unemployment and unionization rates, and indices describing employment protection regulations, level of disability benefits compensation, and efforts to integrate people with disabilities into the workforce. Regulatory moderators represent facilitators and barriers to employment that may reinforce or detract from the effectiveness of IPS. Across 30 sites drawn from 21 randomized controlled trials in 12 countries (33% in the United States), IPS recipients were 2.31 (95% CI 1.99-2.69) times more likely to find competitive employment than recipients of alternative vocational rehabilitation services. The significant competitive-employment rate advantage of IPS over control services increased in the presence of weaker employment protection legislation and integration efforts, and less generous disability benefits. Policy makers should recognize and account for the fact that labor and disability regulations can create an arrangement of incentives that reduces the relative efficacy of supported employment.

BACKGROUND: Case-control study design and disease heterogeneity may be major limiting factors impeding biomarker discovery in brain disorders, including serious mental illnesses. In order to identify biologically/behaviorally driven as opposed to diagnostically driven sub-groups of individuals, we used hierarchical clustering to identify participants with similar patterns of brain activity during a facial Imitate/Observe functional MRI task. METHODS: Participants (N=179; 109 with a schizophrenia spectrum disorder and 70 healthy controls) were scanned at three sites during the performance of the imitate/observe task. Hierarchical clustering was performed to identify data-driven groups of participants who shared similar patterns of neural circuit activation. The number of groups was determined using cluster stability analysis, defined as local minimums for instability across a range from 2 to 10 clusters. The new data-driven groups were compared on social and neurocognitive test performance completed out of the scanner. RESULTS: Three clusters with distinct patterns of neural activity were found. Participants showed greater similarity to their cluster than to their diagnostic category (t(178)=14.0, p=1.3x10-30) or site (p > 0.40). The largest cluster represented ‘typical activators’, with activity in the canonical ‘simulation’ circuit. The other clusters represented a ‘diffuse/inefficient’ activating group, and an ‘efficient/deactivating’ group. The efficient/deactivating group had the highest social cognitive and neurocognitive test scores (F(2, 170)=5.32, p=0.006; post-hoc t tests p

Objective: E-health applications are becoming integral components of general medical care delivery models and emerging for mental health care. Few exist for treatment of those with severe mental illness (SMI). In part, this is due to a lack of models to design such technologies for persons with cognitive impairments and lower technology experience. This study evaluated the effectiveness of an e-health design model for persons with SMI termed the Flat Explicit Design Model (FEDM). Methods: Persons with schizophrenia (n = 38) performed tasks to evaluate the effectiveness of 5 Web site designs: 4 were prominent public Web sites, and 1 was designed according to the FEDM. Linear mixed-effects regression models were used to examine differences in usability between the Web sites. Omnibus tests of between-site differences were conducted, followed by post hoc pairwise comparisons of means to examine specific Web site differences when omnibus tests reached statistical significance. Results: The Web site designed using the FEDM required less time to find information, had a higher success rate, and was rated easier to use and less frustrating than the other Web sites. The home page design of one of the other Web sites provided the best indication to users about a Web site’s contents. The results are consistent with and were used to expand the FEDM. Conclusions: The FEDM provides evidence-based guidelines to design e-health applications for person with SMI, including: minimize an application’s layers or hierarchy, use explicit text, employ navigational memory aids, group hyperlinks in 1 area, and minimize the number of disparate subjects an application addresses.

Background Patients with severe mental illness (SMI) are characterized by an unhealthy lifestyle, which contributes to the widening mortality gap with the general population [1] Changing high levels of sedentary behaviour (SB) and lack of physical activity (PA) is very challenging [2–4]. Effective interventions improving lifestyle in inpatients are still limited, while of all patients with SMI, the hospitalized do have the worst health status. We implemented a MUltidisciplinary Lifestyle Enhancing Treatment for Inpatients with SMI (MULTI), mainly including a daily structure, tailored sports- and work-related activities, attention to dietary habits, psycho-education and participation of staff. It involved a culture change which was implemented based on a ‘change-from-within’-principle, using multidisciplinary* cooperation within the current context and resources of inpatient mental healthcare. * Psychiatrists, activity coordinators, nurse practitioners, dietician and nurses, some of them trained as lifestyle coach. Aim Evaluate changes in physical and mental health and functioning after 18 months compared to treatment as usual (TAU). Methods Observational controlled design including long-term hospitalised inpatients with SMI. We used data from routine screening and a previous cross-sectional study (2013), supplemented by a repeated accelerometer measurement (2015). Patients were included if they received no other intervention related to lifestyle within 18 months after the start of MULTI and if baseline accelerometer data was available. Patients were excluded from analysis if they had a lack of data after 18 months because they (1) were deceased, (2) moved or were discharged from the hospital or (3) had insufficient follow-up accelerometer data. Measures: Accelerometer-measured physical activity (PA) [ActiGraph GT3X+] Metabolic health [weight, abdominal girth, blood-pressure and -levels and metabolic syndrome criteria] Psychotic symptoms [PANSS-r] Quality of life (QoL) [EQ-5D & WHOQoL-Bref] Psychosocial functioning [HoNOS] Analysis hierarchical multilevel regression using change-scores, correcting for baseline outcome-value, age, diagnosis and baseline illness-severity. Results We had sufficient data of 65 patients receiving MULTI and 49 within TAU. Significant (p < 0.05) improvements in total PA (B = 0.5), moderate-to-vigorous PA (B = 1.8%), weight (B = -4.2kg), abdominal girth (B = -3.5cm), systolic blood-pressure (B = -8.0mmHg), HDL-cholesterol (B = 0.1mmol/l) and psychosocial functioning on sums score (B = -3.6), impairment (B = -0.7) and social problems (B = -3.0). No improvements were observed in PA/metabolic health within TAU. Patients receiving MULTI had higher odds to recover from ≥1 metabolic syndrome criterion (OR = 2.06). There was no significant effect on psychotic symptoms. QoL improved significantly in both groups. Discussion Striking results for clinical practice, as much effort and attempts on lifestyle within inpatients with SMI failed to achieve desired improvements, especially in longer term. A turnaround in inpatient mental healthcare: the negative trend of deterioration within these patients can be stopped, relevant parameters can even be positively reversed and negative effects are absent. TAU does not improve physical health A sustainable solution towards a healthier lifestyle in inpatients with SMI at our fingertips, as MULTI was implemented using current context and resources.

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.

Background The case-control design and disease heterogeneity may be major limiting factors impeding biomarker discovery in brain disorders, including serious mental illness such as schizophrenia spectrum disorder (SSD) or bipolar disorder (BPD). We propose that this heterogeneity represents an opportunity for discovery by uncovering relevant biologically driven sub-types within disorders. Individuals with schizophrenia spectrum disorder (SSD) have deficits in social cognition related to poor functional outcome. Methods A total of 109 SSD and 70 matched healthy controls (HC) were recruited across three sites. Participants performed an fMRI task in which they observed or imitated emotional faces. For each participant, an individual pattern of activity (Imitate > Observe for emotional faces) was identified. Hierarchical clustering (Ward’s method) identified clusters of individuals with similar patterns of activity. We then examined whether new data-driven groups of participants (based on patterns of brain activity) demonstrated performance differences on a batter of social and neuro cognitive tests completed out of the scanner. As a validation of the importance of cluster membership, Euclidean distance was compared between participants to members of their own cluster, diagnosis, or site. The clustering analysis was repeated on a replication sample consisting of 32 SSD, 37 euthymic BPD, and 39 HC. Results Three clusters with distinct patterns of neural activity were found. Cluster one (24 HC and 44 SSD) represented ‘typical activators’ (lateral frontal and parietal activity). Cluster two (21 HC and 31 SSD) were identified as ‘hyper-activators’, showing more intense and extended activity. This was interpreted as a ‘compensatory’ response of over-activation related to impaired neural circuits, such as is seen in aging. Interestingly, cluster three (25 Controls and 35 SSD) showed a very atypical pattern, including suppression of activity during imitation in regions involved in the default mode network and/or higher order social cognition (e.g. theory of mind). This group also had improved social cognitive performance relative to the other clusters. Participants were found to have more similar patterns of brain activity to members of their cluster rather than to members of their diagnostic group or scanning site. Importantly, when clustering was applied to the replication sample, the same three patterns (typical activators, hyper activators, and deactivators) were identified. Discussion In independently collected samples, our findings demonstrate different patterns of neural activity among individuals during a socio-emotional task that were independent of DSM-diagnosis or scan site. Our findings may provide objective neuroimaging endpoints (or biomarkers) for subgroups of individuals in target engagement research aimed at enhancing cognitive performance independent of diagnostic category.

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p.001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p.001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

This study compared two contemporary approaches to linking housing and mental health services. In the integrated housing program, case management and housing services were provided by teams within a single agency and were closely coordinated. In the parallel housing condition, case management services were provided by mobile assertive community treatment teams and housing by routine community-based landlords. Adults with severe mental illness who were at high risk for homelessness (n = 121; 72.7% schizophrenia spectrum) were assigned randomly to integrated or parallel housing services and followed for 18 months. Integrated housing services led to more days of stable housing and greater life satisfaction than parallel housing services, especially for male participants. Integrated housing services were also associated with greater reductions in psychiatric symptoms. Closer integration between clinical and housing services, and greater use of supervised living settings, led to more time in stable housing for participants in the integrated housing services condition and was associated with greater gains in several outcome domains.

Background: Severe mental illness (SMI) constitutes a high risk of physical morbidity and physical-related mortality, especially related to diabetes mellitus. Disparities in access to high-quality diabetes mellitus care are suggested to explain a major part of the higher mortality, but information about where to intervene specifically is needed. Hence, we aim to examine if persons with SMI and diabetes mellitus are treated with new improved antiglycemic medication to a lesser degree than persons with diabetes mellitus only.

Background: Hyperprolactinemia, a side effect of antipsychotic treatment, causes amenorrhea, oligomenorrhea, galactorrhea, gynecomastia, and sexual dysfunction. These side effects increase risk of antipsychotic nonadherence and pose significant problems in the long-term management, particularly in women with severe mental illness.

Background: Many people with severe mental illness (SMI) show declines in cognition and motivation. Even though cognitive remediation (CR) is a treatment option for cognitive decline for such population, reduced motivation or ambivalence towards CR interferes with optimal treatment gains. Advances in technologies allow for use of mobile or internet based platforms to practice cognitive exercises. However, it is still unclear whether clinician’s support would help motivate people to practice CR more frequently outside the training session, and thus gain greater benefits, as compared to those without clinician’s support. Methods: In the current study, a total of 30 participants were randomized into either computer-based CR + clinician’s support for motivational enhancement (experimental condition) or computer-based CR with clinician not providing motivational enhancement (control condition). All the subjects in the current study participated in a group-based CR using Lumosity’s games twice a week for 6 weeks, and were given opportunity to practice the games voluntarily outside the treatment session (ie, a maximum of 10 hours a week). Clinicians in the experimental condition were trained to provide key components of motivational enhancement along with providing information about game operation (eg, introducing and demonstrating how to use CR games and answering to participants’ questions about each game), whereas clinicians in control condition were trained only to introduce and demonstrate game operation. Results: The results showed that during a 6-week training phase, participants in the experimental condition (n = 15) voluntarily practiced more hours (20 % played more than 10 hours; 40 % 0~10 hours; 40 % no-playing) outside the treatment sessions than those in control group (n = 15) (0% played more than 10 hours; 20% 0~10 hours; 80% no-playing) (χ2 = 6.000, P = .050). In addition, participants in experimental condition showed greater improvements on functioning and motivational variables including QLS interpersonal, intrapsychic and object subscales (F = 4.872, P = .036 for QLS interpersonal; F = 4.206, P = .050 for intrapsychic; F = 14.235, P = .001 for object) and MAP-SR feelings and motivations about close and caring relationships (F = 10.529, P = .003). Our secondary analyses revealed that extra training hours were positively correlated with improvements in negative symptoms (r = −.518, P = .003) and QLS interpersonal subscale (r = .422, P = .020) and MAP-SR motivation and effort to engage in activities subscale (r = .338, P = .068). Lastly, extra training hours were positively correlated with improvements in TMT-B (r = .454, P = .012), and working alliance with a clinician (r = .459, P = .011). Conclusion: It is concluded that gains in various domains from internet-based CR seem to be further enhanced by clinician’s support for motivation to engage in CR. The current preliminary findings should be replicated in a larger sample.

Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels. This review is based on the findings of 25 randomized controlled trials which assessed the effectiveness of psychosocial interventions, offered either as one-off treatments or as an integrated or nonintegrated program, to reduce substance use by people with a severe mental illness. The findings showed that there was no consistent evidence to support any one psychosocial treatment over another. Differences across trials with regard to outcome measures, sample characteristics, type of mental illness and substance used, settings, levels of adherence to treatment guidelines, and standard care all made pooling results difficult. More quality trials are required that adhere to proper randomization methods; use clinically valuable, reliable, and validated measurement scales; and clearly report data, including retention in treatment, relapse, and abstinence rates. Future trials of this quality will allow a more thorough assessment of the efficacy of psychosocial interventions for reducing substance use in this challenging population.

Background: Excess mortality in severe mental illnesses (SMI) (schizophrenia-spectrum and bipolar disorders) is well described. Little is known about this inequality in ethnic minorities. The aim of this study was to assess mortality in SMI by ethnicity (White British, Black African, Black Caribbean, South Asian, Irish) and assess social and clinical risk factors for excess mortality.

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.

Mental health care for the severely mentally ill in the United States is financed by a combination of public and private funds. Both public and private health insurance programs handle mental illness differently than they do other illnesses. This article documents uninsurance and underinsurance for severe mental illness in the United States based on studies conducted during the last decade. The relationship between private insurance and public assistance is analyzed, and major arguments around equality in insurance coverage for severe mental illness are examined. Alternatives for reducing uninsurance and underinsurance for severe mental illness in order to avoid undertreatment are discussed.

Background. The ecological validity of neurocognitive and functional measures in severe mental illness is poorly understood because of a lack of validated research methods to study community life-as-lived. We describe the development of a video ethnography method that measures naturalistic behaviors with codes called community performance indicators (CPIs). The method could provide a strategy to test the ecological validity of neurocognitive and functional assessments. Methods. We gathered up to 18.5 hours of video ethnography data on each of 9 subjects with schizophrenia selected for high or low composite scores on the MATRICS Consensus Cognitive Battery (MCCB). We used video ethnography to capture subjects’ everyday behaviors in their usual environments. We established 4 CPIs that showed excellent inter-rater and promising test-retest reliability: (1) behavioral activity level, (2) goal pursuit, (3) social interaction, and (4) problem solving. Results. (1) High and low MCCB subjects showed statistically significantly differences on all 4 CPIs. (2) MCCB composite scores were correlated with all 4 CPIs (r = .54 to −.77, P < .01 to .07). (3) The MCCB domain scores demonstrated some specificity in their correlations with the CPIs; eg, verbal learning, reasoning/problem solving, and social cognition were correlated with CPI domains of social interaction and problem solving. Conclusions. We present a method for reliably measuring everyday functional performance in schizophrenia. Results from a small select sample suggest that CPIs capture skills associated with neurocognition, supporting their use in a larger study of ecological validity.

This study examined the effectiveness of cognitive training (the Thinking Skills for Work Program) for improving competitive employment outcomes in persons with severe mental illness who have a history of job failure. Forty-four clients receiving services at 2 inner-city community mental health agencies were randomly assigned (within each site) to receive either cognitive training and supported employment (CT + SE) or supported employment only (SE Only). Retention in the CT + SE program was high (91%). Baseline to 3-month assessments showed significantly greater improvements in neurocognitive functioning, depression, and autistic preoccupation on the Positive and Negative Syndrome Scale for the CT + SE set compared to the SE Only group. Employment outcomes over 1 year showed that clients who received CT + SE were significantly more likely to work (69.6 versus 4.8%, respectively), worked more jobs, worked more hours, and earned more wages than clients with SE Only. The findings provide support for the feasibility of implementing the Thinking Skills for Work Program in the context of supported employment and its beneficial effects on cognitive functioning and competitive employment in persons with severe mental illness.

Impairment in everyday functioning (also referred to as “disability”) is a central feature of schizophrenia (SZ) and bipolar disorder, as well as other neuropsychiatric conditions. There is a genetic contribution to both SZ and bipolar illness (BPI), and the primary putative determinant of impairments in everyday functioning across these 2 conditions, cognitive impairments, also show substantial heritability and in fact have been proposed to be endophenotypes for these disorders. In this article, we review data and make our case that impairments in functional capacity, the functional abilities that result in functional disability, may also be a heritable trait that is common across neuropsychiatric illnesses such BPI and SZ. While there has been little previous research on the heritability of these abilities, it is an area receiving substantial research attention. We consider advances in the measurement of cognitive functioning in SZ that may facilitate the discovery of genetic influences on functional capacity. Functional capacity measures are proximal to real-world impairments, measured with suitable psychometric precision to be used in heritability analyses, and appear to be minimally influenced by environmental factors that may cause disability such as environmental factors, symptoms, and disability compensation. Our conclusion is that these functional capacity measures have potential to be the target of genetic analyses and that these measures should be considered across neuropsychiatric conditions where impairments in everyday functioning are present.