CoChat
Sign Up
Cited by 2,488Schizophrenia research and treatmentMental Health Treatment and AccessPsychiatric care and mental health services

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

Open access
DE HERT, MARC, CORRELL, CHRISTOPH U., BOBES, JULIO, CETKOVICH‐BAKMAS, MARCELO, COHEN, DAN, ASAI, ITSUO, DETRAUX, JOHAN, GAUTAM, SHIV +5 more·2011·World Psychiatry
DOI 10.1002/j.2051-5545.2011.tb00014.xPMC PMC3048500
Open this paper in CoChat — free accountOpen PDF

Abstract

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

AI snapshot

Written from the paper’s full text.

TL;DR

People with severe mental illness (SMI) have substantially elevated physical morbidity and mortality, with excess mortality two to three times that of the general population and a 13–30 year shortened life expectancy. This selective review reports higher prevalence of obesity, metabolic syndrome, diabetes, cardiovascular disease, viral infections, respiratory disease, osteoporosis, sexual dysfunction, pregnancy complications, and oral disease in SMI, alongside medication effects and health care disparities.

Key findings

  • Excess mortality in SMI is two or three times as high as in the general population, translating to a 13–30 year shortened life expectancy; about 60% of this excess mortality is due to physical illness.
  • Obesity is more common in SMI: people with schizophrenia have a 2.8–3.5 increased likelihood of being obese, with reported obesity rates of 42–60%; those with major depression or bipolar disorder have a 1.2–1.5 increased likelihood.
  • Metabolic syndrome is highly prevalent in treated schizophrenia, with estimates between 19.4% and 68%; rates in bipolar disorder and schizoaffective disorder are reported as 22–30% and 42%, respectively. Diabetes prevalence is 2–3 fold higher in schizophrenia, bipolar disorder, and schizoaffective disorder, and 1.2–2.6 times higher with depression or depressive symptoms.
  • Health care disparities are marked: baseline metabolic testing rates for patients starting novel antipsychotics vary between 8% and less than 30%, with follow-up assessments in only 8.8%; in CATIE, non-treatment rate for diabetes was 45.3%, and up to 88% of schizophrenia patients had untreated dyslipidemia and up to 62% untreated hypertension.

Methods

  • Selective, rather than systematic, review of clinical data on physical health problems in people with SMI.
  • Searched MEDLINE (1966–August 2010) combining MeSH terms for schizophrenia, bipolar disorder, and major depressive disorder with MeSH terms for major general physical disease categories; included pertinent reviews and cross-referenced additional relevant studies, sometimes using specific physical illnesses as search terms.
  • Aimed to identify prevalence figures and factors contributing to excess morbidity and mortality, including lifestyle, psychotropic medication effects, and disparities in health care access, utilization, and provision.

Limitations

  • Stated: the review is selective rather than systematic and did not include all physical diseases.
  • Stated: there is a paucity of information and a lack of large, well-designed, prospective comparative studies during pregnancy; data on antidepressant-associated diabetes risk are sparse; cancer findings in SMI are conflicting.
  • Evident: prevalence estimates vary widely by metabolic syndrome criteria, country or region, gender, ethnicity, age group, and antipsychotic treatment, limiting any single summary figure.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/j.2051-5545.2011.tb00014.x

Cites

605 of 605 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 259 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    People with schizophrenia exhibit a higher metabolic syndrome prevalence than their peers in the general population across the world.

    “people with schizophrenia exhibit a higher MetS prevalence than their peers in the general population across the world”
    Quote in the paperNot a substantial claim
  • Findingcitation

    Most children starting treatment with novel antipsychotics do not receive recommended glucose and lipid screening.

    “most children starting treatment with novel AP do not receive recommended glucose and lipid screening”
    Quote in the paperNot a substantial claim
  • Findingcitation

    The metabolic syndrome is highly prevalent among treated patients with schizophrenia.

    “The MetS is highly prevalent among treated patients with schizophrenia”
    Quote in the paperNot a substantial claim
  • Findingnone given
    § WPA EDUCATIONAL MODULE

    People with severe mental illness are less likely to receive standard levels of care for most physical diseases.

    “there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases”
    Quote in the paperSubstantial claim
  • Findingcitation

    In patients with severe mental illness, obesity is associated with lifestyle factors, illness-related factors, and treatment-related factors including weight liability of certain psychotropic agents.

    “In patients with SMI, as in the general population, obesity is associated with lifestyle factors (e.g., lack of exercise, poor diet), but also with illness-related (negative, disorganized and depressive symptoms) and treatment-related factors, including weight liability of certain psychotropic agents”
    Quote in the paperNot a substantial claim
  • The quote only partly states this claim. 2
  • May combine two claims. 75
  • Classified as probably not a substantial claim. 79

  • The quote only partly states this claim.

    Findingcitation

    Persons with severe mental illness are at increased risk for overweight, obesity, and abdominal obesity compared to the general population, even in early illness phase and/or without medication.

    “persons with SMI are, compared to the general population, at increased risk for overweight (i.e., BMI =25-29.9,unless Asian: BMI =23-24.9),obesity (i.e., BMI ≥30, unless Asian: BMI ≥25) and abdominal obesity”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § WPA EDUCATIONAL MODULE

    Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are more prevalent among people with severe mental illness compared to the general population.

    “Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Neither psychiatrists nor primary care physicians carefully screen or monitor patients receiving antipsychotic medication for metabolic risk factors.

    “At present, neither psychiatrists nor primary care physicians carefully screen or monitor patients receiving AP medication for metabolic risk factors”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given
    § WPA EDUCATIONAL MODULE

    Baseline testing of numerous important physical parameters is insufficiently performed in severe mental illness.

    “baseline testing of numerous important physical parameters is insufficiently performed”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    The metabolic syndrome remains widely underdiagnosed and undertreated among patients with severe mental illness.

    “The MetS remains, thus, widely underdiagnosed and undertreated among patients with SMI”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    People with schizophrenia are not being adequately screened and treated for dyslipidemia (up to 88% untreated) and hypertension (up to 62% untreated).

    “people with schizophrenia are not being adequately screened and treated for dyslipidemia (up to 88% untreated) and hypertension (up to 62% untreated)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    It is unclear whether or not specific antidepressants themselves may increase the risk of diabetes mellitus.

    “it is unclear whether or not specific AD themselves may increase the risk of DM”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    People with severe mental illness have significantly higher rates of several modifiable risk factors compared with controls; they are more likely to be overweight or obese, to have diabetes mellitus, hypertension, or dyslipidemia and to smoke.

    “People with SMI have significantly higher rates of several of the modifiable risk factors compared with controls.They are more likely to be overweight or obese, to have DM, hypertension, or dyslipidemia and to smoke”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Severe mental illness patients have the highest cardiovascular disease mortality but the least chance of receiving many specialized interventions or circulatory medications.

    “SMI patients have the highest CVD mortality but the least chance of receiving many specialized interventions or circulatory medications”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    Patients with severe mental illness are at increased risk for a variety of chronic viral infections, of which the most serious are the diseases associated with human immunodeficiency virus and hepatitis C virus.

    “Patients with SMI are at increased risk for a variety of chronic viral infections, of which the most serious are the diseases associated with human immunodeficiency virus (HIV) and hepatitis C virus”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Screening rates for metabolic abnormalities in people with severe mental illness remain low despite clear guidance and a high prevalence of undiagnosed diabetes mellitus, which may lead to prolonged periods of poor glycaemic control.

    “Despite clear guidance and a high prevalence of undiagnosed DM, screening rates for metabolic abnormalities in people with SMI remain low, which may lead to prolonged periods of poor glycaemic control”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisecitation

    In the only study to date in first-episode patients, diabetes mellitus development was promoted by initial treatment with olanzapine (HR=1.41) and mid-potency conventional antipsychotics (HR=1.60), as well as by current treatment with low-potency conventional antipsychotics (OR=1.52), olanzapine (OR=1.44) and clozapine (OR=1.67).

    “In the only study to date in first-episode patients, DM development was promoted in patients with schizophrenia by initial treatment with olanzapine (hazard ratio, HR=1.41) and mid-potency conventional AP (HR=1.60),as well as by current treatment with low-potency conventional AP (odds ratio, OR=1.52), olanzapine (OR= 1.44) and clozapine (OR=1.67)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Weight gain is greatest with clozapine and olanzapine, intermediate with quetiapine and risperidone, and little with aripiprazole, asenapine, amisulpride and ziprasidone.

    “Weight gain is greatest with clozapine and olanzapine (107,108), while quetiapine and risperidone have an intermediate risk.Aripiprazole, asenapine, amisulpride and ziprasidone have little effect on weight”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A large-scale pharmacoepidemiologic study found low to moderate but significantly increased rates of incident diabetes mellitus compared with the general population for clozapine (RR=1.45), olanzapine (RR=1.29) and risperidone (RR=1.23).

    “A recent large-scale pharmacoepidemiologic study (including 345,937 patients who purchased antipsychotics and 1,426,488 unexposed individuals) found low to moderate, but significantly increased rates of incident DM compared with the general population for clozapine (RR=1.45),olanzapine (RR=1.29)and risperidone (RR=1.23)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Studies of genetic predictors of weight gain under antipsychotic therapy have mainly focused on HTR2C and LEPR gene polymorphisms.

    “Studies of genetic predictors of weight gain under AP therapy have mainly but not exclusively (131) focused on HTR2C (132-135) and LEPR (135,136) gene polymorphisms”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is growing evidence for weight gain effects similar to those in schizophrenia in patients with bipolar disorder.

    “There is growing evidence for similar effects in patients with bipolar disorder”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Of the atypical antipsychotics, olanzapine and clozapine and, to a lesser extent, quetiapine and risperidone are associated with an increased risk of diabetes mellitus in people who have schizophrenia or bipolar disorder.

    “Of the atypical AP, specifically olanzapine (231-234) and clozapine (232,234,235) and, to a lesser extent, quetiapine (236) and risperidone (237), are associated with an increased risk of DM (80) in people who have schizophrenia or bipolar disorder”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    High interindividual variability in medication-induced weight gain suggests that genetic factors influence the risk to gain weight.

    “The high interindividual variability in medication-induced weight gain suggests that genetic factors influence the risk to gain weight”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Weight gain during acute and maintenance treatment of patients with schizophrenia is a well established side effect of antipsychotics, affecting between 15 and 72% of patients.

    “Weight gain during acute and maintenance treatment of patients with schizophrenia is a well established side effect of antipsychotics (AP), affecting between 15 and 72% of patients”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The reason for the increased risk of diabetes mellitus in severe mental illness patients is multifactorial and includes genetic and lifestyle factors as well as disease and treatment specific effects.

    “The reason for the increased risk of DM in SMI patients is multifactorial and includes genetic and lifestyle factors as well as disease and treatment specific effects”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Aripiprazole, amisulpride and quetiapine did not have a significantly increased rate of incident diabetes mellitus.

    “Aripiprazole, amisulpride and quetiapine did not have a significantly increased rate”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Antidepressants such as paroxetine and mood stabilizers such as lithium and valproate have been associated with weight gain.

    “Equally, antidepressants (AD) such as paroxetine (116), and mood stabilizers, such as lithium and valproate (117-119), have been associated with weight gain”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Atypical antipsychotics seem to have a stronger diabetogenic risk than conventional antipsychotics, with the risk being 1.3 fold higher in people with schizophrenia taking atypical antipsychotics compared with those receiving conventional antipsychotics.

    “Atypical AP seem to have a stronger diabetogenic risk than conventional AP (96,228,229), the risk being 1.3 fold higher in people with schizophrenia taking atypical AP compared with those receiving conventional AP”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § WPA EDUCATIONAL MODULE

    The somatic well-being of people with severe mental illness has been neglected for decades and still is today.

    “It seems that the somatic well being of people with a (severe) mental illness has been neglected for decades (15), and still is today”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is agreement that the major characteristics of the metabolic syndrome include central obesity, hypertension, dyslipidemia, glucose intolerance or insulin resistance.

    “there is agreement that the major characteristics of the syndrome include central obesity, hypertension, dyslipidemia, glucose intolerance or insulin resistance”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is evidence supporting the hypothesis that the metabolic syndrome or its components may be important etiologic factors for certain cancers, such as colon cancer.

    “There is also evidence supporting the hypothesis that the MetS or components of the MetS may be important etiologic factors for certain cancers (e.g., colon cancer)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is a hierarchy for risk of weight gain with antipsychotics that has been confirmed in different studies and meta-analyses.

    “There is a hierarchy for risk of weight gain with AP that has been confirmed in different studies and meta-analyses”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisecitation

    One large study found that the ten-year coronary heart disease risk was significantly elevated in male (9.4% vs. 7.0%) and female (6.3% vs. 4.2%) patients who have schizophrenia compared to controls (p=0.0001).

    “One large study found that the tenyear coronary heart disease risk was significantly elevated in male (9.4% vs. 7.0%) and female (6.3% vs. 4.2%) patients who have schizophrenia compared to controls (p=0.0001)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The incidence of diabetic ketoacidosis is nearly or more than 10-fold greater in those with schizophrenia compared to the general population.

    “The incidence of DKA is nearly (266) or more (267) than 10-fold greater in those with schizophrenia compared to the general population”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The high frequency of substance abuse, sexual risk behaviors, and reduced knowledge about HIV-related issues contribute to the high HIV prevalence in people with SMI.

    “The high frequency of substance abuse, sexual risk behaviors (e.g., sex without a condom, trading sex for money and drugs), and a reduced knowledge about HIV-related issues contribute to this high HIV prevalence (364,371-376).”
    Quote in the paperNot a substantial claim0 of 7 sources checked
    • cites [364]

      Not checked in the free run.

    • cites [371] source

      Not checked in the free run.

    • cites [372]

      Not checked in the free run.

    • cites [373] source

      Not checked in the free run.

    • cites [374] source

      Not checked in the free run.

    • cites [375]

      Not checked in the free run.

    • cites [376] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The mortality of reported cases of diabetic ketoacidosis varies between 15.4% and 48%, which is up to ten times higher than the 4% rate in the general population.

    “The mortality of reported cases of DKA varies between 15.4% and 48% (233,235-237), which is up to ten times higher than the 4% rate in the general population”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In patients with antipsychotic monotherapy, a dose-related increased risk of sudden cardiac death was found for both conventional and atypical antipsychotics, with adjusted RRs of 1.31 vs. 1.59 for low dose, 2.01 vs. 2.13 for moderate dose, and 2.42 vs. 2.86 for high dose.

    “In patients with AP monotherapy, a similar dose-related increased risk of sudden cardiac death was found for both conventional and atypical AP, with adjusted RRs of 1.31 vs. 1.59 (low dose, chlorpromazine equivalents <100mg), 2.01 vs. 2.13 (moderate dose, chlorpromazine equivalents 100-299mg) and 2.42 vs. 2.86 (high dose, chlorpromazine equivalents ≥300mg), respectively”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The prevalence of cardiovascular disease in people with schizophrenia and bipolar disorder is approximately 2- to 3-fold increased, particularly in younger individuals.

    “The prevalence of CVD in people with schizophrenia and bipolar disorder is approximately 2-to 3-fold increased, particularly in younger individuals”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The largest randomized study to date (n=18,154) did not find a statistically significant difference in the risk of sudden cardiac death between ziprasidone and olanzapine treated patients with schizophrenia.

    “the largest randomized study to date (n=18,154) did not find a statistically significant difference in the risk of sudden cardiac death between ziprasidone and olanzapine treated patients with schizophrenia”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Cases of diabetic ketoacidosis have been reported with the atypical antipsychotics clozapine, olanzapine, quetiapine, risperidone, aripiprazole and ziprasidone.

    “Cases of DKA have been reported with the atypical AP clozapine (235,268), olanzapine (233,269), quetiapine (236), risperidone (237), aripiprazole (270-272) and ziprasidone (242)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The prevalence of HIV positivity in people with severe mental illness (SMI) is generally higher than in the general population, but varies substantially (1.3-23.9%).

    “The prevalence of HIV positivity in people with SMI is generally higher than in the general population, but varies substantially (1.3-23.9%)(347-370).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 347-370

      Not checked in the free run.

  • The quote only partly states this claim.

    Premisecitation

    Current aripiprazole treatment reduced diabetes mellitus risk (OR=0.51) in first-episode patients.

    “Current aripiprazole treatment reduced DM risk (OR= 0.51)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Most antipsychotics and some antidepressants may be associated with QTc prolongation.

    “Most AP and some AD may be associated with QTc prolongation”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Within the class of conventional antipsychotics, cases of diabetic ketoacidosis have been reported with chlorpromazine, but no such cases have been reported for other conventional antipsychotics.

    “Within the class of conventional AP, cases of DKA have been reported with chlorpromazine (274,275), but no such cases have been reported for other conventional AP”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Valproate has been associated with an elevated risk for the development of insulin resistance, conferring a risk for diabetes mellitus, possibly related to weight gain, fatty liver infiltration, but also to valproate itself.

    “certain mood stabilizers, especially valproate, have been associated with an elevated risk for the development of insulin resistance (252,253), conferring a risk for DM, which is possibly related to weight gain (254), and/or fatty liver infiltration (255), but also to valproate itself (256)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning
    § WPA EDUCATIONAL MODULE

    This is a selective, rather than a systematic review of clinical data on physical health problems in people with severe mental illness, as not all physical diseases were included.

    “This is a selective, rather than a systematic review of clinical data on physical health problems in people with SMI, as we did not include all physical diseases”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisecitation

    There are no reported cases of lithium-induced torsade de pointes.

    “There are no reported cases of lithium-induced torsade de pointes”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Overall, SSRIs appear safe in cardiac populations, with few cardiac side effects.

    “Overall, SSRIs appear safe in cardiac populations, with few cardiac side effects”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Fewer than half of individuals with SMI have been tested for HIV in the past year, with percentages ranging from 17% to 47%.

    “However, studies investigating HIV testing rates among individuals with a SMI indicate that fewer than half of these patients (percentages ranging from 17% to 47%) have been tested in the past year (378-394).”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [378] source

      Not checked in the free run.

    • cites [379] source

      Not checked in the free run.

    • cites [380] source

      Not checked in the free run.

    • cites [381] source

      Not checked in the free run.

    • cites [382] source

      Not checked in the free run.

    • cites [383] source

      Not checked in the free run.

    • cites [384] source

      Not checked in the free run.

    • cites [385] source

      Not checked in the free run.

    • cites [386] source

      Not checked in the free run.

    • cites [387] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is a consensus that QTc values >500 msec, or an absolute increase of 60 msec compared with drug-free baseline, puts a patient at significant risk of torsade de pointes, ventricular fibrillation and sudden cardiac death.

    “There is a consensus that QTc values >500 msec, or an absolute increase of 60 msec compared with drug-free baseline, puts a patient at significant risk of torsade de pointes, ventricular fibrillation and sudden cardiac death”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Obesity, diabetes mellitus, cardiovascular disease as well as depressive symptoms are recognized as risk factors for cerebrovascular accident.

    “Obesity, DM, CVD as well as depressive symptoms are recognized as risk factors for cerebrovascular accident”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Antipsychotics associated with a greater risk of QTc prolongation include pimozide, thioridazine and mesoridazine among the conventional antipsychotics and sertindole and ziprasidone among the atypical antipsychotics.

    “AP associated with a greater risk of QTc prolongation include pimozide, thioridazine and mesoridazine among the conventional AP (94,335,336) and sertindole and ziprasidone among the atypical AP”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    One study (n=76,799) found unadjusted ORs of 1.24 for no hemoglobin A1c testing, 1.25 for no low-density lipoprotein cholesterol testing, 1.05 for no eye examination, 1.32 for poor glycemic control, and 1.17 for poor lipaemic control.

    “One study (n=76,799), examining the impact of mental illness on DM management, found the unadjusted OR to be 1.24 (1.22-1.27)for no hemoglobin A(1c) testing, 1.25 (1.23-1.28)for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07)for no eye examination, 1.32 (1.30-1.35)for poor glycemic control, and 1.17 (1.15-1.20)for poor lipaemic control”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Large randomized studies focused on a low incidence serious side effect lack power and, possibly, generalizability.

    “These large randomized studies, which focused on a low incidence serious side effect, suffer from the problem that they did not enrich samples for cardiac risk, so that they lack power and, possibly, generalizability”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patients with schizophrenia have been reported to be three times as likely to experience sudden cardiac death as individuals from the general population.

    “Patients with schizophrenia have been reported to be three times as likely to experience sudden cardiac death as individuals from the general population”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Tricyclic antidepressants commonly increase heart rate by over 10%, induce orthostatic hypotension, slow cardiac conduction, and increase the risk of arrhythmias.

    “Tricyclic AD commonly increase heart rate by over 10%, induce orthostatic hypotension, slow cardiac conduction, and increase the risk of arrhythmias”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Although SSRIs have been associated with QTc prolongation, no cases of torsade de pointes have been reported with the use of these agents.

    “Although SSRIs have been associated with QTc prolongation, no cases of torsade de pointes have been reported with the use of these agents”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Another large randomized study (n=9,858) observed no significant differences between sertindole and risperidone recipients in cardiac events, including arrhythmias, requiring hospitalization.

    “another large randomized study (n=9,858) observed no significant differences between sertindole and risperidone recipients in cardiac events, including arrhythmias, requiring hospitalization”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An analysis of the FDA's diabetes mellitus-related adverse events database found adjusted reporting ratios for diabetes mellitus relative to all drugs and events of olanzapine 9.6, risperidone 3.8, quetiapine 3.5, clozapine 3.1, ziprasidone 2.4, aripiprazole 2.4, and haloperidol 2.0.

    “An analysis of the FDA's DM-related adverse events database (ranging from new-onset hyperglycemia to life-threatening ketoacidosis), found the following adjusted reporting ratios for DM relative to all drugs and events: olanzapine 9.6 (9.2-10.0);risperidone 3.8 (3.5-4.1);quetiapine 3.5 (3.2-3.9);clozapine 3.1 (2.9-3.3);ziprasidone 2.4 (2.0-2.9);aripiprazole 2.4 (1.9-2.9);haloperidol 2.0 (1.7-2.3)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In general, lithium can be safely used in cardiac patients.

    “in general, lithium can be safely used in cardiac patients”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Higher incidence rates of diabetic ketoacidosis for clozapine and olanzapine can be due to reporting and detection biases.

    “higher incidence rates for clozapine and olanzapine can be due to reporting and detection biases”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The aetiology of excess cardiovascular disease in severe mental illness is multifactorial and likely includes genetic and lifestyle factors as well as disease specific and treatment effects.

    “The aetiology of this excess CVD is multifactorial and likely includes genetic and lifestyle factors as well as disease specific and treatment effects”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A systematic review of 22 prospective, randomized, controlled trials found no difference in the incidence of glycaemic abnormalities between placebo cohorts and antipsychotic medication cohorts, as well as no significant difference between any of the antipsychotic medications studied in terms of their association with glycaemic abnormalities.

    “a systematic review of 22 prospective, randomized, controlled trials found no difference in the incidence of glycaemic abnormalities between placebo cohorts and AP medication cohorts, as well as no significant difference between any of the AP medications studied in terms of their association with glycaemic abnormalities”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In the largest study to date, prevalence rates of hepatitis B virus (23.4%) and hepatitis C virus (19.6%) in SMI patients were approximately 5 and 11 times the overall estimated population rates for these infections.

    “The largest study to date found prevalence rates of hepatitis B virus (23.4%) and hepatitis C virus (19.6%) in SMI patients to be approximately 5 and 11 times the overall estimated population rates for these infections.”
    Quote in the paperNot a substantial claim0 of 9 sources checked
    • cites [364]

      Not checked in the free run.

    • cites [396] source

      Not checked in the free run.

    • cites [397] source

      Not checked in the free run.

    • cites [398] source

      Not checked in the free run.

    • cites [399] source

      Not checked in the free run.

    • cites [400] source

      Not checked in the free run.

    • cites [401] source

      Not checked in the free run.

    • cites [402] source

      Not checked in the free run.

    • cites [403] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Patients with SMI exposed to atypical antipsychotics and patients infected with HIV on highly active antiretroviral therapy are at particularly high risk for developing metabolic syndrome and ultimately cardiovascular disease.

    “Since many patients with SMI are exposed to atypical AP, which have been associated with metabolic abnormalities, and since patients infected with HIV and on highly active antiretroviral therapy may also develop metabolic abnormalities, this group of patients is at particularly high risk for developing MetS and ultimately CVD (395).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [395] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent study showed that assignment of people with SMI to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services (testing for hepatitis C, immunization against hepatitis, knowledge about hepatitis).

    “A recent study showed that the assignment of people with SMI to the “STIRR” (Screening, Testing, Immunization, Risk reduction counseling, medical treatment Referral) intervention had high levels (over 80%) of participation and acceptance of core services (testing for hepatitis C, immunization against hepatitis, knowledge about hepatitis) (407).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [407] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Studies consistently show a higher incidence of tuberculosis among patients with schizophrenia compared with the general population.

    “Studies consistently show a higher incidence of tuberculosis among patients with schizophrenia compared with the general population (422-426).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [422]

      Not checked in the free run.

    • cites [423] source

      Not checked in the free run.

    • cites [424]

      Not checked in the free run.

    • cites [425]

      Not checked in the free run.

    • cites [426]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    People with SMI have a higher prevalence of angina and respiratory symptoms and impaired lung function compared with the general population.

    “Filik et al (414) found that people with SMI have a higher prevalence of angina and respiratory symptoms and impaired lung function when compared with the general population.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [414] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a study of 200 outpatients in the US, 15% of those with schizophrenia and 25% of those with bipolar disorder had chronic bronchitis, and 16% of people with schizophrenia and 19% of people with bipolar disorder had asthma.

    “In a study of 200 outpatients in the US, 15% of those with schizophrenia and 25% of those with bipolar disorder had chronic bronchitis, and 16% of people with schizophrenia and 19% of people with bipolar disorder had asthma.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [430] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A higher incidence of chronic obstructive pulmonary disease in the past two decades has been associated with the side effects of phenothiazine conventional antipsychotics, although the association remains unclear.

    “Although the association remains unclear, a higher incidence of chronic obstructive pulmonary disease in the past two decades has been associated with the side effects of phenothiazine conventional AP (434).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [434]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Other studies found an increased or no different overall risk of cancer in patients with schizophrenia compared to the general population.

    “On the other hand, other studies found an increased (9,21,28,(449)(450)(451) or no different (292,419,452,453) overall risk of cancer in patients with schizophrenia compared to the general population.”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [9] source

      Not checked in the free run.

    • cites [21] source

      Not checked in the free run.

    • cites [28] source

      Not checked in the free run.

    • cites [449] source

      Not checked in the free run.

    • cites [450] source

      Not checked in the free run.

    • cites [451] source

      Not checked in the free run.

    • cites [292] source

      Not checked in the free run.

    • cites [419] source

      Not checked in the free run.

    • cites [452] source

      Not checked in the free run.

    • cites [453] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The discrepancy of cancer results may be a result of various confounding factors that could artificially lower the rates of diagnosed and reported cancer in SMI populations.

    “This discrep-ancy of results may be a result of various confounding factors that could artificially lower the rates of diagnosed and reported cancer in SMI populations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    A problem with most existing data base analyses is that etiologically disparate cancer types were lumped together.

    “Nevertheless, a problem with most of the existing data base analyses is that etiologically disparate cancer types were lumped together.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Patients with SMI have a shorter life expectancy, so they may die from cardiovascular reasons before reaching the expected age of death from cancer.

    “Furthermore, patients with SMI have a shorter life expectancy, so they may die from cardiovascular reasons before reaching the expected age of death from cancer (30).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    An important analysis of cause-specific excess deaths associated with underweight, overweight, and obesity in the general population found that obesity was associated with an increased mortality from cancers considered obesity-related but not with mortality from other cancers.

    “An important analysis of cause-specific excess deaths associated with underweight, overweight, and obesity in the general population found that obesity was associated with an increased mortality from cancers considered obesity-related but not with mortality from other cancers (463).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [463] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the population of bipolar spectrum disorders, deaths from cancer are not higher or only slightly elevated compared with the general population, despite the higher number of risk factors for cancer in this population.

    “In the population of bipolar spectrum disorders, deaths from cancer are not higher (8,288,416,417,454-456) or only slightly elevated (417,418,456) compared with the general population, despite the higher number of risk factors for cancer (such as obesity) in this population.”
    Quote in the paperNot a substantial claim0 of 8 sources checked
    • cites [8] source

      Not checked in the free run.

    • cites [288] source

      Not checked in the free run.

    • cites [416] source

      Not checked in the free run.

    • cites [417] source

      Not checked in the free run.

    • cites [454] source

      Not checked in the free run.

    • cites [455] source

      Not checked in the free run.

    • cites [456] source

      Not checked in the free run.

    • cites [418] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    The increased risk of osteoporosis in untreated schizophrenia is due to the disease itself and to risk factors related to lifestyle (e.g., smoking, reduced physical activity, alcohol abuse, vitamin D and calcium deficiency, polydipsia).

    “On the one hand, this is because of the disease itself, on the other hand, because of risk factors related to their lifestyle (e.g., smoking, reduced physical activity, alcohol abuse, vitamin D and calcium deficiency, polydipsia) (470-476).”
    Quote in the paperNot a substantial claim0 of 7 sources checked
    • cites [470] source

      Not checked in the free run.

    • cites [471] source

      Not checked in the free run.

    • cites [472] source

      Not checked in the free run.

    • cites [473] source

      Not checked in the free run.

    • cites [474]

      Not checked in the free run.

    • cites [475] source

      Not checked in the free run.

    • cites [476] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The majority of studies investigating the risk of breast cancer in patients treated with conventional antipsychotics did not uncover an increased risk of breast cancer, with an exception being the cohort study by Wang et al.

    “The majority of the studies in which the risk of breast cancer has been investigated in patients treated with conventional AP (465-468) did not uncover an increased risk of breast cancer, an exception being the cohort study by Wang et al (469).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [465]

      Not checked in the free run.

    • cites [466]

      Not checked in the free run.

    • cites [467] source

      Not checked in the free run.

    • cites [468] source

      Not checked in the free run.

    • cites [469] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The current study database on antipsychotics and breast cancer risk is very limited.

    “The current study database on AP and breast cancer risk is very limited (464).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [464] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Two recent meta-analyses confirmed that depression is associated with low bone mineral density and should be considered as an important risk factor for osteoporosis, although this increased risk may be mediated by antidepressants.

    “Two recent meta-analyses confirmed that depression is associated with low BMD and should be considered as an important risk factor for osteoporosis, although this increased risk may be mediated by AD (484,485).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [484] source

      Not checked in the free run.

    • cites [485] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Some studies found a relationship between the use of prolactin-raising medication and low bone mineral density in patients with chronic schizophrenia, while others failed to find a relationship between prolactin, antipsychotics and osteoporosis.

    “Some studies (490-493) found a relationship between the use of prolactin-raising medication and low BMD in patients with chronic schizophrenia, while others (474,489,494-498) failed to find a relationship between prolactin, AP and osteoporosis.”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [490] source

      Not checked in the free run.

    • cites [491] source

      Not checked in the free run.

    • cites [492] source

      Not checked in the free run.

    • cites [493] source

      Not checked in the free run.

    • cites [474]

      Not checked in the free run.

    • cites [489] source

      Not checked in the free run.

    • cites [494] source

      Not checked in the free run.

    • cites [495] source

      Not checked in the free run.

    • cites [496] source

      Not checked in the free run.

    • cites [497] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although the association between depression and loss of bone mineral density has been reported inconsistently, most studies have found low bone mineral density in patients with depressive symptoms or major depressive disorder.

    “Although the association between depression and loss of BMD has been reported inconsistently, most studies have found low BMD in patients with depressive symptoms or major depressive disorder (477-483).”
    Quote in the paperNot a substantial claim0 of 7 sources checked
    • cites [477] source

      Not checked in the free run.

    • cites [478] source

      Not checked in the free run.

    • cites [479] source

      Not checked in the free run.

    • cites [480] source

      Not checked in the free run.

    • cites [481] source

      Not checked in the free run.

    • cites [482] source

      Not checked in the free run.

    • cites [483] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Data describing the epidemiology of osteoporotic fracture and psychotropics in patients with SMI are limited.

    “Data describing the epidemiology of osteoporotic fracture and psychotropics in patients with SMI are limited.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Although lithium has a potentially negative impact on bone metabolism, it is associated with lower fracture risk (OR=0.6) and seems to be protective against fractures.

    “Although lithium has a potentially negative impact on bone metabolism (470), it is associated with lower fracture risk (OR=0.6)and, thus, seems to be protective against fractures (504,505).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [470] source

      Not checked in the free run.

    • cites [504] source

      Not checked in the free run.

    • cites [505] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A meta-analysis showed a 33% increased risk of fractures with SSRIs compared to non-SSRI antidepressants; the RR of fractures was 1.60 for antidepressants and 1.59 for antipsychotics.

    “A metaanalysis showed a 33% increased risk of fractures with SSRIs compared to non-SSRI AD.The RR of fractures in this metaanalysis was 1.60 for AD and 1.59 for AP (511).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [511] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Sexual dysfunction in schizophrenia is estimated to be more frequent compared to normal controls and to affect 30-80% of women and 45-80% of men.

    “Although there are relatively few systematic investigations concerning sexual disorders in schizophrenia (514), sexual dysfunction in schizophrenia is, compared to normal controls, estimated to be more frequent (515-519) and to affect 30-80% of women and 45-80% of men (512,515, 520-523).”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [515] source

      Not checked in the free run.

    • cites [516] source

      Not checked in the free run.

    • cites [517]

      Not checked in the free run.

    • cites [518] source

      Not checked in the free run.

    • cites [519] source

      Not checked in the free run.

    • cites [512] source

      Not checked in the free run.

    • cites [520] source

      Not checked in the free run.

    • cites [521] source

      Not checked in the free run.

    • cites [522] source

      Not checked in the free run.

    • cites [523] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sexual dysfunction in SMI patients has received little attention from clinicians.

    “Sexual dysfunction in SMI patients has received little attention from clinicians (512,513).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [512] source

      Not checked in the free run.

    • cites [513] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    This low awareness has a significant negative impact on patients' satisfaction with treatment, adherence, quality of life and partner relationships.

    “This low awareness has a significant negative impact on patients' satisfaction with treatment, adherence, quality of life and partner relationships (450).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [450] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sexual dysfunction is also a common symptom of depression.

    “Sexual dysfunction is also a common symptom of depression (526-530).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [526] source

      Not checked in the free run.

    • cites [527] source

      Not checked in the free run.

    • cites [528] source

      Not checked in the free run.

    • cites [529]

      Not checked in the free run.

    • cites [530] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Approximately 25% of patients with major depression may experience problems with erection or lubrication.

    “Approximately 25% of patients with major depression may experience problems with erection or lubrication (531).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [531] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Conventional antipsychotics cause less sexual dysfunction than risperidone but more than the other novel antipsychotics.

    “Conventional AP cause less sexual dysfunction than risperidone but more than the other novel AP (520,522).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [520] source

      Not checked in the free run.

    • cites [522] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Up to 70% of patients with depression may have sexual dysfunction.

    “Up to 70% of patients with depression may have sexual dysfunction (466).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [466]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Only few studies have directly compared the sexual functioning associated with different atypical antipsychotics.

    “To date, only few studies (534-547) have directly compared the sexual functioning associated with different atypical AP.”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [534] source

      Not checked in the free run.

    • cites [535] source

      Not checked in the free run.

    • cites [536] source

      Not checked in the free run.

    • cites [537] source

      Not checked in the free run.

    • cites [538] source

      Not checked in the free run.

    • cites [539] source

      Not checked in the free run.

    • cites [540] source

      Not checked in the free run.

    • cites [541] source

      Not checked in the free run.

    • cites [542] source

      Not checked in the free run.

    • cites [543] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Findings suggest that sexual health education for people with SMI tends to produce a reduction in sexual risk behavior.

    “However, findings suggest that sexual health education for these people tends to produce a reduction in sexual risk behavior (532).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [532] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    This dysfunction can be secondary to the disease itself and to comorbid physical disorders, or be an adverse event of antipsychotics.

    “This dysfunction can be secondary to the disease itself and to comorbid physical disorders, or be an adverse event of AP (520,524,525).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [520] source

      Not checked in the free run.

    • cites [524] source

      Not checked in the free run.

    • cites [525]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The relative impact of antipsychotics on sexual dysfunction can be summarized as: paliperidone = risperidone > haloperidol > olanzapine ≥ ziprasidone > clozapine ≥ quetiapine > aripiprazole.

    “These studies suggest that the relative impact of AP on sexual dysfunction can be summarized as: paliperidone = risperidone > haloperidol > olanzapine ≥ ziprasidone > clozapine ≥ quetiapine > aripiprazole (503,520,536).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [503]

      Not checked in the free run.

    • cites [520] source

      Not checked in the free run.

    • cites [536] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Antidepressant therapy (except for mirtazapine, nefazodone and bupropion) frequently induces or exacerbates sexual dysfunction, which occurs in approximately 50% of patients.

    “AD therapy (except for mirtazapine, nefazodone and bupropion) frequently induces or exacerbates sexual dysfunction, which occurs in approximately 50% of patients (548).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [548] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Psychotropic drugs are associated with sexual dysfunction.

    “Psychotropic drugs are associated with sexual dysfunction (514).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [514]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Although sexual dysfunction has been reported with all classes of antidepressants, SSRIs are associated with higher rates.

    “Although sexual dysfunction has been reported with all classes of AD (549), SSRIs are associated with higher rates (550-552).”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [549] source

      Not checked in the free run.

    • cites [550] source

      Not checked in the free run.

    • cites [551]

      Not checked in the free run.

    • cites [552] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is an extensive literature reporting an increased occurrence of obstetric complications among women who have schizophrenia.

    “There is an extensive literature reporting an increased occurrence of obstetric complications among women who have schizophrenia (15).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Current evidence seems to suggest that Fallot's tetralogy is not considerably elevated with lithium compared to the rate in the general population.

    “Current evidence seems to suggest that Fallot's tetralogy is not considerably elevated with lithium compared to the rate in the general population (560).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [560] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Dental health has been consistently found to be poor in people with SMI.

    “Dental health has been consistently found to be poor in people with SMI (562-573).”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [562]

      Not checked in the free run.

    • cites [563] source

      Not checked in the free run.

    • cites [564] source

      Not checked in the free run.

    • cites [565]

      Not checked in the free run.

    • cites [566] source

      Not checked in the free run.

    • cites [567]

      Not checked in the free run.

    • cites [568] source

      Not checked in the free run.

    • cites [569] source

      Not checked in the free run.

    • cites [570] source

      Not checked in the free run.

    • cites [571] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Most women with SMI cannot stop taking their medication, as this would interfere with their activities of daily living, especially taking care of an infant.

    “Most women with a SMI cannot stop taking their medication, as this would interfere with their activities of daily living, especially taking care of an infant (555).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [555] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Among antidepressants, SSRIs and, possibly, serotonin and noradrenaline reuptake inhibitors have been associated with preterm labor, respiratory distress, serotonin rebound syndrome, pulmonary hypertension and feeding problems in the neonate.

    “Among AD, SSRIs and, possibly, serotonin and noradrenaline reuptake inhibitors (SNRIs) have been associated with preterm labor, respiratory distress, serotonin rebound syndrome, pulmonary hypertension and feeding problems in the neonate (557-559).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [557] source

      Not checked in the free run.

    • cites [558] source

      Not checked in the free run.

    • cites [559] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Published studies suggest that between 30% and 60% of SSRI-treated patients may experience some form of treatment-induced sexual dysfunction.

    “Published studies suggest that between 30% and 60% of SSRI-treated patients may experience some form of treatment-induced sexual dysfunction (553,554).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [553]

      Not checked in the free run.

    • cites [554] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In one large study (n=4,769), 34.1% of the patients with SMI reported that oral health problems made it difficult for them to eat.

    “In one large study (n=4,769), 34.1% of the patients with SMI reported that oral health problems made it difficult for them to eat (572).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [572] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    This poor dental health leads to functional difficulties.

    “This poor dental health leads to functional difficulties.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Oral health status is a frequently disregarded health issue among SMI patients, with low rates of dental examination within the past 12 months.

    “Oral health status is a frequently disregarded health issue among SMI patients (498), with low rates of dental examination within the past 12 months (569,577-579).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [498] source

      Not checked in the free run.

    • cites [569] source

      Not checked in the free run.

    • cites [577]

      Not checked in the free run.

    • cites [578] source

      Not checked in the free run.

    • cites [579] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Antipsychotics, antidepressants and mood stabilizers all cause xerostomia.

    “AP, AD and mood stabilizers all cause xerostomia (575).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [575] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    According to another study, only 42% of patients with schizophrenia brush their teeth regularly (at least twice a day).

    “According to another study, only 42% of patients with schizophrenia brush their teeth regularly (at least twice a day) (573).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [573] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A study using an overall dental status index (DMF-T) in chronically hospitalized patients with mental disorders (mostly schizophrenia) found a mean score of 26.74 (out of a possible 32), one of the highest reported in the literature.

    “A study using an overall dental status index (DMF-T) in chronically hospitalized patients with mental disorders (mostly schizophrenia) found a mean score of 26.74 (out of a possible 32), one of the highest reported in the literature (571).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [571] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    This reduction in salivary flow changes the oral environment and leads to caries, gingivitis and periodontal disease.

    “This reduction in salivary flow changes the oral environment and leads to caries, gingivitis and periodontal disease (576).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [576] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Factors which influence oral health include: type, severity, and stage of mental illness; mood, motivation and self-esteem; lack of perception of oral health problems; habits, lifestyle (e.g., smoking), and ability to sustain self-care and dental attendance; socio-economic factors; effects of medication (dry mouth, carbohydrate craving); and attitudes and knowledge of dental health teams about ​​​

    “Factors which influence oral health include: type, severity, and stage of mental illness; mood, motivation and selfesteem; lack of perception of oral health problems; habits, lifestyle (e.g., smoking), and ability to sustain self-care and dental attendance; socio-economic factors; effects of medication (dry mouth, carbohydrate craving); and attitudes and knowledge of dental health teams concerning”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [569] source

      Not checked in the free run.

    • cites [574]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Some physical conditions, although important, are rarely studied, underreported and not systematically assessed.

    “Some physical conditions, although important, are rarely studied, underreported and not systematically assessed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Clozapine (approximately 0.8%) and phenothiazines (chlorpromazine approximately 0.13%) are the most common causes of drug-related neutropenia/agranulocytosis.

    “Clozapine (approximately 0.8%) and phenothiazines (chlorpromazine approximately 0.13%) are the most common causes of drug-related neutropenia/agranulocytosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Poor dental status is associated with endocarditis and reduces social and work opportunities.

    “Moreover, improving dental health status and care are relevant, as poor dental status is associated with endocarditis and reduces social and work opportunities.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    In addition to modifiable lifestyle factors and psychotropic medication side effects, poorer access to and quality of received health care remain addressable problems for patients with SMI.

    “In addition to modifiable lifestyle factors and psychotropic medication side effects, poorer access to and quality of received health care remain addressable problems for patients with SMI.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Although a common side effect of antipsychotics that can be severe and lead to serious consequences and even death, constipation has been given relatively little attention.

    “Although a common side effect of AP that can be severe and lead to serious consequences and even death, constipation has been given relatively little attention.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Constipation has most widely been reported for clozapine, although it can be associated with other antipsychotics as well.

    “Constipation has most widely been reported for clozapine, although it can be associated with other AP as well.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Prevalence of constipation in randomized controlled trials for different antipsychotics is: zotepine 39.6%, clozapine 21.3%, haloperidol 14.6% and risperidone 12%.

    “Prevalence of constipation in randomized controlled trials for different AP is: zotepine 39.6%, clozapine 21.3%, haloperidol 14.6% and risperidone 12% (583).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [583] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the latter study, non-adherence to annual dental visits was predicted by substance abuse diagnosis, involuntary legal status, living in an institution, admission to a psychiatric facility for a minimum of 30 days, and male gender, whereas clozapine treatment, novel antipsychotic treatment, at least monthly outpatient visits, and age > 50 years were associated with a lower risk for inappropriate

    “In the latter study, non-adherence to annual dental visits was predicted by substance abuse diagnosis, involuntary legal status, living in an institution, admission to a psychiatric facility for a minimum of 30 days, and male gender, whereas clozapine treatment, novel AP treatment, at least monthly outpatient visits, and age > 50 years were associated with a lower risk for inappropriate dental”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [577]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The most reported complications of constipation are paralytic ileus, faecal impaction, bowel obstruction and intestine/bowel perforations.

    “The most reported complications of this physical condition are paralytic ileus, faecal impaction, bowel obstruction and intestine/bowel perforations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Haematological diseases have frequently been described in the literature as potential serious complications of psychotropic medications.

    “Haematological diseases, which may in themselves be primary problems in patients with SMI, have frequently been described in the literature as potential serious complications of psychotropic medications.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    With appropriate management, the mortality from drug-induced agranulocytosis in Western countries is 5-10% (before the use of antibiotics this percentage was 80%).

    “With appropriate management, the mortality from drug-induced agranulocytosis in Western countries is 5-10% (before the use of antibiotics this percentage was 80%) (582).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [582] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In one study of a mixed psychiatric population, 15% had not been to a dentist in the last 2 years, while in another only 31% of schizophrenia patients had visited a dentist during a three year period.

    “In one study of a mixed psychiatric population, 15% had not been to a dentist in the last 2 years (579), while in another only 31% of schizophrenia patients had visited a dentist during a three year period (577).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [579] source

      Not checked in the free run.

    • cites [577]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Greater individual and system level attention to these physical disorders that can worsen psychiatric stability, treatment adherence, and life expectancy as well as quality of life will improve outcomes of these generally disadvantaged populations worldwide.

    “Greater individual and system level attention to these physical disorders that can worsen psychiatric stability, treatment adherence, and life expectancy as well as quality of life will improve outcomes of these generally disadvantaged populations worldwide.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Antipsychotics (e.g., clozapine, haloperidol, olanzapine, phenothiazines, quetiapine, risperidone, ziprasidone), antidepressants (e.g., amitriptyline, clomipramine, imipramine) as well as lithium are associated with blood dyscrasias.

    “AP (e.g., clozapine, haloperidol, olanzapine, phenothiazines, quetiapine, risperidone, ziprasidone), AD (e.g., amitriptyline, clomipramine, imipramine) as well as lithium are associated with blood dyscrasias.”
    Quote in the paperNot a substantial claim
122 of 122

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Upper diabetic ketoacidosis mortality is twelvefold, not tenfold

    Minor

    The upper reported mortality of 48% is 12 times the general-population rate of 4%, exceeding the stated maximum of ten times.

    Reported 10 · recomputed 12

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 16

  1. Mental and Physical Health Platform., 2008, Mental and physical health charter. Bridging the gap between mental and physical health
  2. Parks J, 2006, Morbidity and mortality in people with serious mental illness
  3. Citrome L, 2007, Risk‐benefit analysis of available treatments for schizophrenia, Psychiatric Times, 1, 27
  4. Scheen A, 2008, Traitement neuroleptique et troubles metabolic, Med Mal Metabol, 2, 593
  5. World Health Organization Department of Noncommunicable Disease Surveillance., 1999, Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus
  6. Whiting D, 2010, Equity, social determinant and public health programmes, 77
  7. Department of Health., 2001, Diabetes national service framework
  8. Casey DE, 2004, Antipsychotic‐induced weight gain and metabolic abnormalities: implications for increased mortality in patients with schizophrenia, J Clin Psychiatry, 65, 4
  9. Nicol G, 2009, Preliminary results of the MEAC study: metabolic effects of antipsychotics in children, Schizophr Bull, 35, 32
  10. Pies RW, 2001, Antipsychotics: the heart of the problem, Psychiatric Times, 18, 26
  11. Lönnroth K, 2010, Equity, social determinants and public health programmes, 219
  12. Hammerschmidt S, 2009, Lung cancer: current diagnosis and treatment, Dtsch Arztebl Int, 106, 809
  13. Dupont A, 1986, Psychiatric case registries in public health, 229
  14. MalikP.Cross‐sectional study of bone density in patients with schizophrenic or schizophreniform disease.Dissertation Leopold‐Franzens University Innsbruck 2001.
  15. Montejo AL, 2001, Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients, J Clin Psychiatry, 62, 10
  16. Kwan S, 2010, Equity, social determinants and public health programmes, 159

Cited by

Sorted by citations

Related

Authors
DE HERT, M., CORRELL, C. U., BOBES, J., CETKOVICH‐BAKMAS, M., COHEN, D., ASAI, I., DETRAUX, J., GAUTAM, S., MÖLLER, H., NDETEI, D. M., NEWCOMER, J. W., UWAKWE, R., & LEUCHT, S.
Affiliations
  • Albert Einstein College of Medicine (US)
  • Universidad de Oviedo (ES)
  • University of Groningen (NL)
  • KU Leuven (BE)
  • SMS Medical College (IN)
  • University of Nairobi (KE)
  • Washington University in St. Louis (US)
  • Nnamdi Azikiwe University (NG)
  • Technical University of Munich (DE)
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2011-02
Volume
10
Issue
1
Pages
52-77
ISSN
  • 1723-8617 (ISSN-L)
  • 2051-5545
DOI
10.1002/j.2051-5545.2011.tb00014.x
PMC
PMC3048500
OpenAlex
W2116251861
Semantic Scholar
611c371ce31e6dedc3d58ef6f711b7a21edbc450
Cited by
2,488
References
605
Citations by year
2026: 119 · 2025: 142 · 2024: 159 · 2023: 174 · 2022: 209 · 2021: 190 · 2020: 224 · 2019: 181 · 2018: 171 · 2017: 162 · 2016: 186 · 2015: 147 · 2014: 112 · 2013: 216 · 2012: 68
FWCI
93.34
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 770 d)
Locations
  • World Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • University of Nairobi Research Archive (University of Nairobi) (submittedVersion)
  • Lirias (KU Leuven) (submittedVersion)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
  • University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
Funders
  • American Heart Association
  • Bristol-Myers Squibb
  • Pfizer
  • Società Italiana di Psichiatria Biologica
  • National Heart, Lung, and Blood Institute
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
Keywords
severe mental illness, physical illness, comorbidities, excess mortality, psychotropic medication side effects, health care disparities, lifestyle factors, cardiovascular disease, obesity, sexual dysfunction, screening, schizophrenia, bipolar disorder, major depressive disorder

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review