Mortality from causes other than suicide is higher than expected in schizophrenia. Cardiovascular causes are most common, accounting for the majority of the 5% of sudden and unexpected deaths. Most cases have no clear explanation on post-mortem examination (‘sudden unexplained deaths’) and are thought to result from fatal arrhythmias. Prospective studies show that people with prolongation of the QT interval beyond 500 ms are at increased risk of serious arrhythmias such as ventricular tachycardia and torsade de pointes. In about 1 in 10 cases, the torsade is fatal. Most antipsychotics prolong the QTc interval in overdose but some prolong it even at therapeutic doses. Droperidol, sertindole and ziprasidone extend the QT interval by an average of 15–35 ms; quetiapine, haloperidol and olanzapine by 5 ms, to 15 ms. There is only an approximate relationship between QT prolongation and risk of sudden death, and the risk related to antipsychotics is thought to increase in people with pre-existing cardiac disease, those taking multiple QT-acting drugs and those taking antipsychotics at high dose for long periods. There is little evidence of an association with route of administration. More data are required to clarify to what extent people with mental health difficulties who die suddenly have pre-existing cardiac disease.
Available evidence does not yet allow accurate comparison of the quantitative risk of serious cardiovascular side-effects or sudden cardiac death for all antipsychotics, not least because several agents have not been examined in sufficient detail. Nevertheless, an elevated risk of serious adverse Abstract Cardiac safety of antipsychotic drugs continues to be a concern for both typical and atypical antipsychotics.Risk appears greatest in those with pre-existing cardiac disease but many patients may have occult cardiovascular disease. In addition, several drugs appear to increase the likelihood of diabetes and weight gain, which may have an additive adverse effect. On the basis of risk of sudden cardiac death and risk of QTc prolongation we suggest considering antipsychotics in two categories -higher and lower risk. Of most concern is the use of large cumulative doses of antipsychotics that are sometimes given inadvertently by different prescribers. Clinicians need to be aware how to read an ECG, and how to monitor physical parameters and interpret the significance of QTc prolongation in relation to antipsychotic prescribing. We suggest provisional guidance on antipsychotic monitoring in relation to cardiac safety but acknowledge that future studies will help clarify which antipsychotic drugs and which concomitant risk factors are most important for those with and without established cardiac disease.Nasser Abdelmawla is a specialist registrar in psychiatry. He completed his PhD in psychopharmacology and has an interest in druginduced adverse effects. Alex Mitchell is a consultant in liaison psychiatry at
and child abuse. Also, in high-income countries as people enjoy more privileges, they tend to take less responsibility for their actions and expect more and more from the state. We increasingly see more pressure on social services, rather than on parents, to account for the welfare of children. This does not mean that borderline personality disorder is exclusive to the West, but in the social context we do see more reasons for people in the West to have such traits. Given the aetiological factors that we are aware of, and the crucial age factor for borderline personality disorder, it is no surprise that immigration is not a risk factor for borderline personality disorder. This is an interesting study that confirms what was earlier suggested by Tyrer et al 4 and Baleydier et al; 5 however, I am not sure whether a similar study in future would be useful, given that it is unlikely that immigration can be a risk factor for developing borderline personality disorder. I do, however, agree with the authors that future studies in younger immigrants and second generations who will be more influenced by the Western way of life are likely to be interesting and helpful, especially in terms of clinical management.
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