The edition · Psychiatry
Physical illness stacks up decades early in severe mental illness
A 178,665-person Queensland cohort shows people with schizophrenia or bipolar disorder accumulate multi-system physical disease far younger, a large database study links GLP-1 agonists to lower mortality in this group, and rapid relapse after stopping paliperidone is not a withdrawal effect.
The edition in brief
A statewide Queensland cohort compared 30,189 people with schizophrenia-spectrum or bipolar disorder against 148,476 age- and sex-matched hospital comparators over 24 years. Adjusted subdistribution hazard ratios for accumulating physical disease rose with each additional organ system affected: 1.85 for at least one, 2.25 for two, 2.65 for three, 2.93 for four, 3.16 for five. In absolute terms, at 20 years there were 18.43 additional cases per 100 people with disease in at least two systems. The gap was widest in the young — women under 25 with five or more affected systems had an adjusted hazard ratio of 9.24. Median age at cohort entry was 32. A target trial emulation in 1,528,230 propensity-matched adults found GLP-1 receptor agonist initiation associated with lower 4-year mortality than SGLT2 inhibitor initiation, and more so in serious mental illness: 4.91% versus 6.45% (hazard ratio 0.76, 95% CI 0.74 to 0.78, absolute difference 1.54 percentage points). This is observational, and the implausibly large 1-year effect should prompt caution. An individual participant data meta-analysis of five paliperidone discontinuation trials found two relapse trajectories, rapid and delayed, but rapid relapse was no commoner after discontinuation than during continued treatment — arguing against a pharmacological withdrawal effect. Baseline symptom severity predicted rapid relapse. A SMART trial in 316 anxious youths found fluoxetine, CBT, their combination and different sequences all produced similar symptom reduction. Today's pearl: the annual physical health check for severe mental illness needs a named owner.
Multi-system physical disease arrives decades early in severe mental illness
Begin metabolic and physical health monitoring at the first presentation of psychosis or bipolar disorder — the divergence from the general population is steepest in patients under 25.
Rapid relapse after stopping paliperidone is not a withdrawal effect
When discussing antipsychotic reduction, stratify by baseline symptom severity rather than fearing a withdrawal-specific relapse — rapid relapse was no commoner after stopping than during continued treatment.
GLP-1 agonists and mortality in serious mental illness: a big signal from weak evidence
Where a patient with serious mental illness has a metabolic indication for a GLP-1 agonist, prescribe it — but treat the mortality figures in this database study as directional rather than real.
The physical health check needs a name against it, not a recommendation
Write a named clinician against physical health monitoring for every patient with severe mental illness, and attach the check to a contact that already happens.
Paediatric anxiety: fluoxetine, CBT and combinations all worked about equally
In paediatric anxiety, start with whichever of fluoxetine or CBT the family will engage with, and if it is not working at 12 weeks, optimise it rather than automatically adding the other.
No new regulatory action for the desk today
Nothing new from the regulators today — use the time to check that metabolic monitoring is actually happening for the antipsychotics you have already prescribed.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for psychiatry, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free