Dott.ssa CRISTINA CROCAMO -...

Dott.ssa CRISTINA CROCAMO

Università degli Studi di Milano Bicocca

[email protected]

Fondazione Castellini, 20 giugno 2016

DISTURBI CARDIOVASCOLARI E METABOLICI IN DISTURBI MENTALI


Cardiovascular disease (CVD) Cerebrovascular disease (CVA) Coronary heart disease (CHD)

Obesity Diabetes Mellitus

Metabolic Syndrome

Relatore

Note di presentazione

The cluster of cardiovascular and diabetes risk factors known as MetS

Disturbi cardiovascolari e metabolici in disturbi mentali DISTURBI CARDIOVASCOLARI E METABOLICI

IN DISTURBI MENTALI

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Epidemiology evaluates the incidence, prevalence, distribution and control of a disease in a specific or selected population. Unfortunately, our knowledge of the metabolic syndrome in the USA must be considered wanting in most of these areas.

and metabolic disorders

25 692 unique people suffering from schizophrenia from 27 countries or regions

AIM to clarify the prevalence and predictors of metabolic syndrome (MetS) in adults with schizophrenia and related disorders, accounting for subgroup differences.

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Minor differences BY COUNTRY Country N studies n ATP III MetS rates USA 26 7037 32.5% (26.6%-38.7%) Finland 5 158 34.5% (25.4%-44.2%) Turkey 9 702 30.1% (24.7%-35.8%) Spain 6 2187 30.2% (23.6%-37.2%)

The overall rate of MetS was 32.5% (95%CI 30.1– 35.0)

MetS ATP III

MetS adapted ATP III

MetS IDF

N studies 80 12 15 Sample size 17005 2716 1266 Pooled (%) 95%CI

32.8 (30.0-35.7)

28.6 (19.8-38.3)

35.3 (23.1-48.6)

Relatore


The overall rate of MetS was 32.5% (95%CI 30.1– 35.0) using any standardized MetS criteria. The rates using the adapted ATP III, or IDF definitions were 28.6% (N = 12, n = 2716, 95% CI = 19.8%–38.3%); and 35.3% (N = 15, n = 1266, 95% CI = 23.1%–48.6%), respectively.

The overall rate of MetS was 32.5% (95%CI 30.1– 35.0) Obesity Hypert Tryglic Glu>110 Glu>100 HDL Smoking Diabetes

N studies 53 72 77 47 28 76 41 14 Sample size 14305 18657 19831 13784 6499 19280 5759 2186

Pooled (%) 95%CI

49.4 (45-53)

38.7 (36-42)

39.3 (35-44)

19.5 (17-22)

18.8 (15-22)

42.6 (39-46)

54.3 (51-57)

10.9 (7-15)

• Obesity ATP (Waist M>102, F>88 cm) • Hypertension BP >130/85 mmHg • Tryglicerides>150 mg/dl • Glycemia ATP III (Glucose >110 mg/dl or Glucose>100 mg/dl) • HDL (M<40, F<50 mg/dl)

Relatore


The overall rate of MetS was 32.5% (95%CI 30.1– 35.0) using any standardized MetS criteria. The rates using the ATP III, adapted ATP III, or IDF definitions were 32.8% (N = 80, n = 17005, 95% CI = 30.0%–35.7%); 28.6% (N = 12, n = 2716, 95% CI = 19.8%–38.3%); and 35.3% (N = 15, n = 1266, 95% CI = 23.1%–48.6%), respectively.

SUBGROUP EFFECTS (MetS) • Clinical setting inpatients 30.4% (26.7%-34.2%) outpatients 31.8% (27.5%–36.2%). • Gender males 34.8% (29.2%–40.6%) females 34.8% (29.5%–40.3%)

MetS PREDICTORS (Different MetS rates) • Age ≥50 years 39.2% (32.6%–46.1%) statistically significant difference • Illness duration (>7.8 years) • Prescriptions (clozapine) 51.9% (45.8%–57.9%) but they were likely to be linked with covariates of age and illness duration.

Waist size is the most predictive of the full syndrome at a study level. AUC =0.848 (0.756 to 0.941)

Sensitivity=79.4% Specificity=78.8%

MetS components

more valid and reliable predictor than BMI of risk for

-Type 2 diabetes (T2DM) -Cardiovascular disease (CVD) -MetS and other metabolic-related conditions

Ref. Parks J, Svendsen D, Singer P et al (eds). Morbidity and mortality in people with serious mental illness. Alexandria: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, 2006


Stronger indicator for systolic blood pressure, HDL, triglycerides

Meta-analysis 30 included studies (the oldest published in 2007) 7616 individuals: 1632 SD, 5376 SCZ, 608 ONAP. MetS pooled prevalence rate was of 36.8% (31.4–42.3%)

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Relatore


Bartoli F, Crocamo C, Caslini M, Clerici M, Carrà G. Schizoaffective disorder and metabolic syndrome: A meta-analytic comparison with schizophrenia and other non-affective psychoses. J Psychiatr Res. 2015;66-67:127-34. doi: 10.1016/j.jpsychires.2015.04.028. 30 independent samples, involving 7616 unique individuals who suffered from SD, SCZ or ONAP, of whom 2865 had MetS. Our hypothesis that individuals with SD were more likely to be affected by MetS is confirmed. Patients with SD had an OR (95% CI) for MetS of 1.41 (1.23-1.61), as compared with SCZ/ONAP.

Schizoaffective vs SCZ and ONAP

OR=1.41 95%CI (1.23-1.61)

*Findings not influenced by any single study

Relatore


People with psychotic disorders, including schizophrenia (SCZ), schizoaffective disorder(SD), or other non-affective psychoses (ONAP), have a higher risk of metabolic syndrome (MetS) than general population. Schizoaffective disorder is a condition in which a person experiences a combination of schizophrenia symptoms — such as hallucinations or delusions — and mood disorder symptoms, such as mania or depression.

Mixed random effects meta-analysis 37 studies 6983 individuals suffering from Bipolar Disorder data on MetS prevalence rates

AIMS 1. to clarify the prevalence rate of MetS in people with bipolar disorder, taking into account variations in several study characteristics 2. comparing the prevalence of MetS in people with BD and age- and gender-matched healthy comparison subjects.

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Relatore


Bipolar Disorder Vancampfort… http://www.ncbi.nlm.nih.gov/pubmed/23361837

Standardized criteria

MetS ATP III

MetS adapted ATP

III

MetS IDF

N studies 37 18 10 11 Sample size 6983 2204 2799 1321 Pooled (%) 95%CI

37.3 (36.1-39.0)

29.9 (28.0-31.9)

41.5 (39.6-43.4)

35.6 (33.0-38.2)

The distribution of prevalence rates of individual studies was not homogeneous the variability between studies is larger than can be expected on the basis of

sampling error (considerable heterogeneity) potential role of study design and several study characteristics

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Bipolar Disorder Vancampfort… http://www.ncbi.nlm.nih.gov/pubmed/23361837 HETEROGENEITY Clinical variation will lead to heterogeneity if the intervention effect is affected by the factors that vary across studies; most obviously, the specific interventions or patient characteristics. In other words, the true intervention effect will be different in different studies. Differences between studies in terms of methodological factors, such as use of blinding and concealment of allocation, or if there are differences between studies in the way the outcomes are defined and measured, may be expected to lead to differences in the observed intervention effects. Significant statistical heterogeneity arising from methodological diversity or differences in outcome assessments suggests that the studies are not all estimating the same quantity, but does not necessarily suggest that the true intervention effect varies.

Obesity Hypert Tryglic Glu>110 Glu>100 HDL Smoking N studies 11 17 18 8 4 17 4 Sample size 4573 2615 1718 2204 2593 1861 1136

Pooled (%) 95%CI

48.7 (46-51)

47.1 (45-49)

39.3 (38-41)

11.4 (9-14)

17.3 (15-20)

42.1 (41-44)

45.5 (42-52)

• Obesity ATP (Waist M>102, F>88 cm) • Hypertension BP >130/85 mmHg • Tryglicerides>150 mg/dl • Glycemia ATP III and ATPIII-A/IDF (Glucose >110 mg/dl or Glucose>100 mg/dl) • HDL (M<40, F<50 mg/dl)

MetS prevalence 37.3% with 95%CI (36.1-39.0) using standardized criteria

Relatore


The overall rate of MetS was 32.5% (95%CI 30.1– 35.0) using any standardized MetS criteria. The rates using the ATP III, adapted ATP III, or IDF definitions were 32.8% (N = 80, n = 17005, 95% CI = 30.0%–35.7%); 28.6% (N = 12, n = 2716, 95% CI = 19.8%–38.3%); and 35.3% (N = 15, n = 1266, 95% CI = 23.1%–48.6%), respectively.

• Geographical region highest in New Zealand/Australia • Age MetS rate

No statistically significant differences in terms of • MetS Definition criteria • Illness duration • Setting

64.2% (38.3–83.9)

Relatore


Bipolar Disorder Vancampfort… http://www.ncbi.nlm.nih.gov/pubmed/23361837 Greater age: higher MetS prevalence

Antipsychotics greater risk of MetS OR=1.72 95%CI (1.24-2.38) MetS rates: 45.3% (39.6-50.9) vs. 32.4% (27.5-37.4)

6/37 studies data on MetS prevalence rates in people taking antipsychotics N=298 taking antipsychotics N=339 antipsychotic free

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OR= 1.98 (1.74-2.25) MetS is twice as common among people suffering from BD as among the general population.

Suggestions multiple measurements of parameters during the first year of treatment. Encouraging people to exercise, make dietary changes, stop smoking.

COMPARATIVE META-ANALYSIS 6/37 studies BD Vs. Healthy subjects

N=1252 N=87861 48% Men 45.2% Men mean age 42.2 (5.2) yrs. mean age 41.1 (6.3) yrs.

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Random effects meta-analysis 11 studies data on MetS prevalence rates

3888 participants

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Despite important differences in clinical features individuals with bipolar disorder and schizophrenia have comparable chances of having metabolic syndrome The number of individuals with metabolic syndrome was 705 among bipolar patients and 890 among schizophrenia patients.

Comparable chances of having metabolic syndrome Pooled analysis: Random-effects model

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A pooled analysis based on a random-effects model and using odds ratio as an association measure The pooled odds ratio (bipolar compared with schizophrenia) was 1.01 (95% CI 0.82–1.24; p=0.93), with low heterogeneity across the studies (I2=31%; p=0.15). Despite important differences in clinical features individuals with bipolar disorder and schizophrenia have comparable chances of having metabolic syndrome

Comparable chances of having metabolic syndrome

common health behaviors -poor physical activity -unhealthy diet -excessive alcohol intake -smoking habits

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Despite important differences in clinical features individuals with bipolar disorder and schizophrenia have comparable chances of having metabolic syndrome

Pooled analysis and meta-regression 16 studies n = 158834 individuals suffering from MDD data on diabetes prevalence rates (observational studies) AIMS 1. to clarify the prevalence and predictors of diabetes 2. to compare the prevalence in those with MDD vs. controls.

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Major Depression Vancampfort… http://onlinelibrary.wiley.com/doi/10.1002/da.22387/abstract

31% male mean age range 39–78 years

Evidence of heterogeneity (I² = 93.9%; 95% CI 92.2–95.1%).

T2DM Prevalence was 8.7% , 95% CI 7.3–10.2%.

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Major Depression Vancampfort… http://onlinelibrary.wiley.com/doi/10.1002/da.22387/abstract

META-REGRESSION (MDD only) -Age: higher prevalence of T2DM (P = 0.03) 22% of heterogeneity

No significant effect: -% of male participants -Region (Europe, North America, Asia, Australia) -Level of education (yrs) -Smoking rate -Illness duration -Medication use (% of antipsychotics, antidepressants)

COMPARATIVE ANALYSIS (MDD vs. controls)

-General population controls RR = 1.49, 95% CI 1.29–1.72 MDD at a higher risk of T2DM -age- and gender-matched controls (selected subsample) RR=1.36, 95% CI = 1.28–1.44

Pooled analysis 13 studies n = 589781 individuals suffering from PTSD and controls data on obesity rates (observational studies)

AIM To examine the association between PTSD and obesity

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Relatore


PTSD Bartoli F, Crocamo C, Alamia A, Amidani F, Paggi E, Pini E, Clerici M, Carrà G. Posttraumatic stress disorder and risk of obesity: systematic review and meta-analysis. J Clin Psychiatry. 2015;76(10):e1253-61. doi: 10.4088/JCP.14r09199. Review. http://www.ncbi.nlm.nih.gov/pubmed/26528647 7.Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M. Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord. 2013;11(5):301-8. doi: 10.1089/met.2013.0010. Epub 2013 Jun 11. Review. Bartoli F, Crocamo C, Clerici M, Carrà G. The association between PTSD and metabolic syndrome: A role for comorbid depression? Metabolism. 2015;64(11):1373-5. doi: 10.1016/j.metabol.2015.07.017.

OBESITY Pooled OR=1.55 95%CI (1.32-1.82) -High heterogeneity (I2 = 90%) -Risk of publication bias (P = 0.002).

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OBESITY Sensitivity analysis with studies with most accurate methods to assess obesity OR = 1.35 (1.05-1.74); I2 = 47%

individuals suffering from PTSD seem more likely, relative to controls, to suffer from obesity.

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METABOLIC SYNDROME

Pooled analysis, random effects meta regression 6 studies n = 528 individuals suffering from PTSD and n = 846 controls data on MetS rates (observational studies)

AIM estimating the association between PTSD and metabolic syndrome

Previous evidence: high prevalence of obesity, diabetes, hypertension, and dyslipidemia

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METABOLIC SYNDROME

The pooled OR for MetS was 1.37 95%CI (1.03-1.82)

Individuals suffering from PTSD are more likely to have MetS

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METABOLIC SYNDROME (2)

MetS overall rate of 38.7% (95% CI: 32.1%–45.6%) from nine independent samples, including 9673 individuals with PTSD

Previous evidence

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Relatore


Comorbid depression as a key clinical factor explaining high rates of MetS. PTSD Bartoli F, Crocamo C, Alamia A, Amidani F, Paggi E, Pini E, Clerici M, Carrà G. Posttraumatic stress disorder and risk of obesity: systematic review and meta-analysis. J Clin Psychiatry. 2015;76(10):e1253-61. doi: 10.4088/JCP.14r09199. Review. http://www.ncbi.nlm.nih.gov/pubmed/26528647 7.Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M. Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord. 2013;11(5):301-8. doi: 10.1089/met.2013.0010. Epub 2013 Jun 11. Review. http://www.ncbi.nlm.nih.gov/pubmed/23758060 Bartoli F, Crocamo C, Clerici M, Carrà G. The association between PTSD and metabolic syndrome: A role for comorbid depression? Metabolism. 2015;64(11):1373-5. doi: 10.1016/j.metabol.2015.07.017.

METABOLIC SYNDROME (2) Random effects meta-analysis 3/10 studies n = 344 individuals suffering from PTSD mainly males (80%) n = 171 suffering from depression vs. n = 68 (2 studies) data on MetS rates (observational studies) and comorbid depression

AIM Exploring the association between DEPRESSION and MetS among people with PTSD.

Previous evidence: high rates of MetS in people with PTSD.

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Comorbid depression as a key clinical factor explaining high rates of MetS. PTSD Bartoli F, Crocamo C, Alamia A, Amidani F, Paggi E, Pini E, Clerici M, Carrà G. Posttraumatic stress disorder and risk of obesity: systematic review and meta-analysis. J Clin Psychiatry. 2015;76(10):e1253-61. doi: 10.4088/JCP.14r09199. Review. http://www.ncbi.nlm.nih.gov/pubmed/26528647 7.Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M. Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord. 2013;11(5):301-8. doi: 10.1089/met.2013.0010. Epub 2013 Jun 11. Review. http://www.ncbi.nlm.nih.gov/pubmed/23758060 Bartoli F, Crocamo C, Clerici M, Carrà G. The association between PTSD and metabolic syndrome: A role for comorbid depression? Metabolism. 2015;64(11):1373-5. doi: 10.1016/j.metabol.2015.07.017.


OR= 2.45 (95%CI: 0.98–6.15; p = 0.06) for MetS and depression in PTSD, with moderate–high heterogeneity (I2 = 68%; p = 0.04).

Overall 39% (95% CI: 34%–44%) With Depression 47% (95% CI: 39%–54%) Without Depression 21% (95% CI: 12%–31%)

Relatore


Posttraumatic stress disorder (PTSD) is a mental health condition affecting people directly or indirectly exposed to one or more traumatic events (i.e., actual or threatened death, serious injury, or sexual violence), and causing clinically significant distress and impairment in social, occupational, or other important areas of functioning. Comorbid depression as a key clinical factor explaining high rates of MetS. Parameters: waist circumference and blood pressure values, and routine fasting glucose and lipids profiles PTSD Bartoli F, Crocamo C, Alamia A, Amidani F, Paggi E, Pini E, Clerici M, Carrà G. Posttraumatic stress disorder and risk of obesity: systematic review and meta-analysis. J Clin Psychiatry. 2015;76(10):e1253-61. doi: 10.4088/JCP.14r09199. Review. http://www.ncbi.nlm.nih.gov/pubmed/26528647 7.Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M. Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord. 2013;11(5):301-8. doi: 10.1089/met.2013.0010. Epub 2013 Jun 11. Review. http://www.ncbi.nlm.nih.gov/pubmed/23758060 Bartoli F, Crocamo C, Clerici M, Carrà G. The association between PTSD and metabolic syndrome: A role for comorbid depression? Metabolism. 2015;64(11):1373-5. doi: 10.1016/j.metabol.2015.07.017.


Suggestions (people suffering from PTSD) comprehensive cardio-metabolic assessment regular assessment of metabolic disorders, especially for those people

with co-occurring depressive disorders. evaluation of lifestyle habits, regular measurement of parameters (standard monitoring)

role for comorbid depression

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Posttraumatic stress disorder (PTSD) is a mental health condition affecting people directly or indirectly exposed to one or more traumatic events (i.e., actual or threatened death, serious injury, or sexual violence), and causing clinically significant distress and impairment in social, occupational, or other important areas of functioning. Comorbid depression as a key clinical factor explaining high rates of MetS. Parameters: waist circumference and blood pressure values, and routine fasting glucose and lipids profiles PTSD Bartoli F, Crocamo C, Alamia A, Amidani F, Paggi E, Pini E, Clerici M, Carrà G. Posttraumatic stress disorder and risk of obesity: systematic review and meta-analysis. J Clin Psychiatry. 2015;76(10):e1253-61. doi: 10.4088/JCP.14r09199. Review. http://www.ncbi.nlm.nih.gov/pubmed/26528647 7.Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M. Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord. 2013;11(5):301-8. doi: 10.1089/met.2013.0010. Epub 2013 Jun 11. Review. http://www.ncbi.nlm.nih.gov/pubmed/23758060 Bartoli F, Crocamo C, Clerici M, Carrà G. The association between PTSD and metabolic syndrome: A role for comorbid depression? Metabolism. 2015;64(11):1373-5. doi: 10.1016/j.metabol.2015.07.017.

AIMS 1. to establish prevalence rates of MetS 2. testing hypotheses about putative reasons for the excess in the SMI group.

Comparative study n = 208 people with DSM-IV diagnosis of SMI n = 196 controls from maxillofacial surgery

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5.Carrà G, Bartoli F, Carretta D, Crocamo C, Bozzetti A, Clerici M, Bebbington PE. The prevalence of metabolic syndrome in people with severe mental illness: a mediation analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1739-46. doi: 10.1007/s00127-014-0835-y. http://www.ncbi.nlm.nih.gov/pubmed/24562318

MetS prevalence rate was 26.1% in the SMI group vs. 15.9% in the comparison group.

MetS ATP-III definition 1. abdominal obesity >102 cm (M) and >88 (F) 2. fasting triglycerides concentration ≥150 mg/dl 3. blood pressure ≥ 130/85 mmHg (or on antihypertensive

medication). 4. HDL cholesterol <40 mg/dl (M) and <50 mg/dl (F) 5. fasting glucose concentration ≥ 110 mg/dl (or on insulin or

hypoglycaemic medication).

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These factors could not entirely explain the excess of MetS in the SMI group

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AIM to explore the prevalence of cardiovascular disease (CVD) risk factors in people with severe mental illness (SMI)

Comparative study n = 119 SMI n = 119 controls

MetS ATP-III –A definition 1. obesity BMI ≥30 kg/m2

2. fasting triglycerides concentration≥200 mg/dl 3. blood pressure ≥140/90 mmHg

or on antihypertensive medication 4. LDL cholesterol ≥160 mg/dl 5. fasting blood glucose level ≥126 mg/dl or on

insulin or hypoglycemic medication.

*

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4.Clerici M, Bartoli F, Carretta D, Crocamo C, Bebbington P, Carrà G. Cardiovascular risk factors among people with severe mental illness in Italy: a cross-sectional comparative study. Gen Hosp Psychiatry. 2014;36(6):698-702. doi: 10.1016/j.genhosppsych.2014.08.005. http://www.ncbi.nlm.nih.gov/pubmed/25217493

.

• only prevalence of obesity and hypertriglyceridemia higher in people with SMI than in those without

• No mediation by antipsychotic dose: such drugs do not contribute much to the excess

• Region with distinct dietary traditions, but also poor healthy behaviors such as smoking.

• Smoking: p=0.065 SMI 77 (64.7%) Controls 63 (52.9%)

Relatore


4.Clerici M, Bartoli F, Carretta D, Crocamo C, Bebbington P, Carrà G. Cardiovascular risk factors among people with severe mental illness in Italy: a cross-sectional comparative study. Gen Hosp Psychiatry. 2014;36(6):698-702. doi: 10.1016/j.genhosppsych.2014.08.005. http://www.ncbi.nlm.nih.gov/pubmed/25217493

Cardiovascular disease (CVD) People with SMI are at higher risk

for cardiovascular morbidity and mortality than their counterparts in the general population

– SCHIZOPHRENIA and BIPOLAR DISORDER: up to 3-fold higher – DEPRESSION: up to 5-fold higher

Ref. De Hert et al. World Psychiatry 2011;10:52-77. De Hert et al. Eur Psychiatry 2009;24:412-424. Vetter et al. Circulation 2008;117:2407-2423.

Score Relative Risk table

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Use an algorithm, monitoring form, or risk chart during the patient’s screening

Coronary heart disease (CHD) in SMI patients

Risk of CHD higher in SMI patients – SCHIZOPHRENIA: 2 to 3.6-fold increased risk – BIPOLAR DISORDER: 2.1-fold increased risk

Ref. De Hert et al. World Psychiatry 2011;10:52-77.

Cerebrovascular disease (CVA) in SMI patients

Risk of CVA higher in SMI patients – SCHIZOPHRENIA: 1.5 to 2.9- fold increased risk – BIPOLAR DISORDER: 2.1 to 3.3-fold increased risk

Ref. De Hert et al. World Psychiatry 2011;10:52-77.

PREVALENCE RATES for MetS SCZ BD PTSD Range 20-68% 30-49% 30-72% Pooled 32-37% 30-41% 38-39% Risk 2-3 1.5-2 1.4

Large variations in prevalence estimates across -definitions -countries or regions -gender -age groups

Obesity

Triglycerides

HDL-cholesterol

Blood pressure

Glucose

Obesity at increased risk for obesity compared to the general population (2-3 times). 48-49%

• lifestyle factors (e.g., poor diet, poor exercise) • illness-related factors (e.g., depressive symptoms) • treatment-related factors

Hypertension

Tryglicerides

at increased risk for hypertension compared to the general population (2-3 times). 39-47%

Glycemia

at increased risk for hypertrygliceridemia (2-3 times). 38-39%

at increased risk for hypertrygliceridemia (1.4 times). 11-19%

Diabetes mellitus (DM)

Prevalence GENERAL POPULATION 3-4% of the world’s population have DM

Prevalence of DM in SMI patients is higher compared with the general population

• SCHIZOPHRENIA, BIPOLAR DISORDER, SCHIZOAFFECTIVE

DISORDER: 2-3 times higher • DEPRESSION: 1.2-2.6 times higher

References De Hert M, Correll CU, Bobes J, et al. World Psychiatry 2011;10:52-77.

http://www.ncbi.nlm.nih.gov/pubmed/21379357 Mitchell AJ, Vancampfort D, Sweers K. et al. Schizophr Bull. 2013;39:306-18.

http://www.ncbi.nlm.nih.gov/pubmed/22207632 Vancampfort D, Mitchell AJ, De Hert, et al. Depression and Anxiety 2015;32:763-773.

http://www.ncbi.nlm.nih.gov/pubmed/26114259 Vancampfort D, Vansteelandt K, Correll CU, et al. Am J Psychiatry. 2013;170:265-74.

http://www.ncbi.nlm.nih.gov/pubmed/23361837

UNIMIB Bartoli F, Carrà G, Crocamo C, et al. Am J Psychiatry. 2013;170:927-8.

http://www.ncbi.nlm.nih.gov/pubmed/23903338 Bartoli F, Carrà G, Crocamo C, et al. Metab Syndr Relat Disord. 2013;11:301-8.

http://www.ncbi.nlm.nih.gov/pubmed/23758060 Bartoli F, Crocamo C, Caslini M, et al. J Psychiatr Res. 2015;66-67:127-34.

http://www.ncbi.nlm.nih.gov/pubmed/26004300 Bartoli F, Crocamo C, Alamia A, et al. J Clin Psychiatry 2015;76:e1253-e1261.

http://www.ncbi.nlm.nih.gov/pubmed/26528647 Bartoli F, Crocamo C, Clerici M, Carrà G. Metabolism. 2015;64:1373-5.

http://www.ncbi.nlm.nih.gov/pubmed/26350126 Carrà G, Bartoli F, Carretta D, et al. Soc Psychiatry Psychiatr Epidemiol.2014;49:1739-46.

http://www.ncbi.nlm.nih.gov/pubmed/24562318 Clerici M, Bartoli F, Carretta D et al. General Hospital Psychiatry 2014;36:698-702.

http://www.ncbi.nlm.nih.gov/pubmed/25217493

http://www.ncbi.nlm.nih.gov/pubmed/21379357�











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Cristina Crocamo, Francesco Bartoli, Giuseppe Carrà

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