Schizophrenia Drugs and Metabolic Risks

Chapter 1: Introduction

1.0 Overview of Topic

Schizophrenia is considered a serious mental disorder that makes people abnormally interpret reality. The people affected by the disorder develop hallucinations, delusions, disoriented thinking and express abnormal behaviour which impairs their ability to effectively function in a daily manner (Müller, 2018). It is argued by Green et al. (2019) that the exact cause of schizophrenia is not able to be identified but various biological and environmental factors are responsible to support the development of the disease. In order to control the adverse effect of schizophrenia in people, anti-psychotic medications are mainly used as pharmacological intervention and there is range of anti-psychotic medication used in the management of the disease (Müller, 2018). However, it is argued by Carrión et al. (2018) that most of them are seen to cause an adverse metabolic impact on the health of schizophrenic individuals. The adverse effect often includes weight gain, hyperglycaemia diabetic ketoacidosis and others (Carrión et al., 2018). In this critical analysis practice, different existing studies are to be evaluated to understand these varied metabolic impacts caused by the use of antipsychotic medication for schizophrenic adult patients. For this purpose, critical appraisal of different related studies is to be presented which are to be collected by using a secondary search strategy.

1.1 Rationale of the Study

Schizophrenia is a severe and chronic mental disorder that is associated to cause hindered education and occupational performance as a result of the disorder and it is nearly affecting 20 million people globally of all age groups (Gage et al., 2017). In the UK, 1 in 100 people suffer an episode of schizophrenia in their lifetime. This is equal to 14.5 per 1000 people (approx.) to be considered to suffer schizophrenia-related disorder (hallucination, delusions, etc) or schizophrenia (livingwithschizophreniauk.org, 2018). It indicates fewer population in the UK are affected by the disorder, but it is one of the most disabling disease which is affecting the mankind. This is because it interferes with the everyday performance of actions by the people required to live their life with well-being. The NICE mentions that the use of anti-psychotic medication such as risperidone, clozapine, asenapine, aripiprazole and others is to be made for the treatment of schizophrenia (NICE, 2014). It is argued by Højlund et al. (2021), the use of antipsychotic medication has wider side effects that disrupt the normal metabolic condition of individuals with schizophrenia and makes them develop weight gain, dizziness, restlessness, hyperlipidaemia and others. This is evident from the study of Dayabandara et al. (2017) where it is mentioned that 15-72% of patient using anti-psychotic medication experiences weight gain and diabetes as metabolic disorder. Thus, the issue is that antipsychotic medication that are the key pharmacological intervention for managing schizophrenia led individual to experience adverse metabolic health condition. The hindered metabolic effect of anti-psychotic medication in adult schizophrenia patients is an issue because the weight gain caused as a result of the effect further has worsened impact on the mental health of the patients. This is because increased weight gain leads schizophrenic patients to face increased, lower self-esteem and higher anxiety (Potkin et al., 2020). It is evident as overweight schizophrenic patients develop insecurity regarding their body and are stigmatised in society to be isolated for their mental as well as physical appearance that negatively impacts their psychological condition (Larsen et al., 2019). It is argued by Grimm et al. (2017), emotionally disrupted schizophrenia patients at times develop overeating habit and avoid antipsychotic medication use out of concern regarding the body weight. The weight gain caused as a result of antipsychotic medication use in schizophrenic patients is an issue because it also leads the individuals to develop the additional risk of cardiovascular disease and hindered physical activity (Scheewe et al., 2019). A argued by Townsend (2018), the metabolic effect of anti-psychotic medication in schizophrenic patients leads them to develop hyperglycaemia. The condition leads schizophrenic patients to required additional care regarding diabetes management and makes them be at risk of developing heart diseases and others (Townsend, 2018). The metabolic effect of antipsychotic medication use in schizophrenic patients is currently an issue because it is found to contribute to shortening lifespan and increased morbidity among patients (Ratna et al., 2019). It is also argued by Ratna et al. (2019), effective services are not been discussed regarding the way the anti-psychotic medication adverse metabolic impact on schizophrenia patients are to be managed and avoided. Thus, the current study is to be developed so that the management strategies to overcome the adverse metabolic effect of antipsychotic medication use in schizophrenic patient can be determined. As criticised by Haddad and Correll (2018), people with schizophrenia using anti-psychotic medication are prone to be five times more vulnerable in becoming obese compared to the general population. This indicates that the metabolic impact of anti-psychotic medication in schizophrenic patients are leading them to develop worsened health condition. Thus, in this study, the extent to which the antipsychotic medication is responsible for causing adverse metabolic impact on schizophrenic patients are to be evaluated as it would provide an overview regarding the prevalence of effects.

1.3 Significance of the Study

The significance of executing the study is that it would highlight if the anti-psychotic medication actually causes hindered metabolic impact on the schizophrenic patient and way issues raises the condition to be caused with the administration of medication. This would help the health professionals to develop medical evidence regarding the risk and explore the causes of the condition to determine the strategies that may be taken to overcome the situation.

1.4 Aim

The study aims to investigate the metabolic effects of antipsychotics medication use in adults with schizophrenia.

1.5 Research Question

The development of a well-defined research question is important for the study because it helps to inform in detail the key focus of the specific topic and defines the problem raised that guides the researchers to develop an understanding of search strategies to be taken in fulfilling the study (Saaiq and Ashraf, 2017). The well-framed research question also informs about the sort of reading required for gathering data in conducting the study (Saaiq and Ashraf, 2017). In this research, the research question is to be framed by following the PICO framework. The PICO framework stands for population (P), intervention (I), comparison (C) and outcome (O). The population is the key individuals who are focused in the study. The intervention is the actions taken in the research that is to be discussed. The comparison is referred to any comparative variable considered in the study and the outcomes mention the results expected to be developed from the study.

Population (P)= Adults with Schizophrenia

Intervention (I)= Anti-psychotic medication on metabolic condition of schizophrenia patients

Comparison (C)= No

Outcome (O)= identifying reason and nature of metabolic effect due to use of antipsychotic medication and way to control the effects

Research Question: What are the metabolic effects of antipsychotics medication use in adults with schizophrenia?

Chapter 2: Literature Review

2.0 Introduction

The chapter focuses on the existing research articles relevant to the topic to be explored to provide conceptual knowledge regarding the key variable in the study. Moreover, the chapter focuses to present the related models and theories that link with Schizophrenia and metabolic effects of anti-psychotic medication to present theoretical information regarding the key variables.

2.1 Concept of Anti-psychotic medication

Anti-psychotic medications are also called neuroleptics which are the class of medical drugs used for managing psychosis disorder in individuals. The first-generation anti-psychotic medication is known as typical anti-psychotics and they were mainly introduced in the 1950s and others were developed in the 1970s (López-Muñoz et al., 2018). In contrast, the second-generation anti-psychotic medication are known as atypical anti-psychotic medications (Townsend, 2018). The two generations of anti-psychotic medication are effective in blocking the dopamine produced in the brain, but the atypical anti-psychotic medications are seen to act as serotonin receptors in controlling the neurological functioning of the patients (Kamarudin and Parhar, 2019). However, the choice of the nature of anti-psychotic medication to be prescribed is dependent on the treatment purpose regarding how severe the symptoms and health problems are to be managed. It is argued by Kamarudin and Parhar (2019) that anti-psychotic medications vary in the way they work such as some has higher sedating efficiency than others due to which physicians specifically mention the dose to be maintained to avoid increased adversities. The typical and atypical anti-psychotic medications are seen to work with equal efficiency, but the exception faced is with clozapine which is the only new generation anti-psychotic medication that works in better way compared to other typical anti-psychotic medications (Salmas et al., 2017). As argued by Malik et al. (2019), intake of clozapine is seen to create various adverse side-effect. This leads the patients to recommend taking it are required to systematically perform a blood test to remain aware of its side-effected during the course of its administration.

2.2 Medical uses of anti-psychotic medication

The anti-psychotic medications are the key pharmaceutical treatment intervention for schizophrenic individuals. This is because the medications help to lower the positive symptoms regarding psychosis which includes hallucinations and delusions (Jeon and Kim, 2017). However, there is mixed evidence available that proves the impact of psychotic medications on the management of negative symptoms of schizophrenia such as emotional condition, lack of interest in social communication and others (Kumar et al., 2018). The psychotic medications are also routinely used in treatment of bipolar disorder as the first-line of intervention to manage manic and mixed psychological episodes related to the condition (Jawad et al., 2018). The key psychotic medications used in the treatment of bipolar disorder are quetiapine and olanzapine or monotherapy which are found to be effective in controlling manic, depressive and mixed bipolar disorder (Haddad and Correll, 2018). It is argued that 80% of the people with dementia living in the care or nursing homes are found to develop agitation and psychosis. In this condition, anti-psychotic medications are used for the elderly, but they derive various serious adverse events due to which they are not routinely used for the patients (Isaac et al., 2021). The anti-psychotic medications are also used in treatment of the posttraumatic-stress disorder, personality disorder, autism, Tourette syndrome and others. The aggressive challenging behaviour showcased by adults suffering from intellectual disability are often considered to be treated with anti-psychotic medications even though there is lack of evidence to support the action (Kumar et al., 2018).

2.3 Mechanism of action of anti-psychotic medication in adults

The mechanism of action of anti-psychotic medications are varied like haloperidol and chlorpromazine acts on the dopaminergic pathway in the brain by blocking the dopamine D2 receptors in them. This is to execute to lower the release of dopamine in the brain and reduce its effects since excess dopamine release in the mesolimbic pathway is linked with expression of psychotic symptoms in individuals (Hendouei et al., 2019). It is argued by Wang et al. (2020) that lower release of dopamine from the prefrontal cortex and higher release of dopamine from the other areas leads to the expression of symptoms regarding bipolar disorder and schizophrenia. Moreover, the dopamine’s antagonist impact created by the use of anti-psychotic medications acts to antagonise the effect of 5-HT2A receptors. The different allele present regarding the 5-HT2A receptors is found to be related with the management of schizophrenia in individuals (Wang et al., 2020). The typical anti-psychotic medications do not specifically block dopamine receptor in certain part of the brain but act to block them in different areas such as nigrostriatal pathway, tuberoinfundibular pathway and mesocortical pathway. The blockage of the D2 receptors in the different pathway is considered to support development of certain side effects in the body (Preller et al., 2018). As argued by Żołek et al. (2018), the potency of the anti-psychotic medications is determined based on their ability and affinity to bind with the dopamine in the brain and does not indicate the efficiency of the impact of the drug. Thus, the high potency anti-psychotic medications are delivered in few dosages compared to the low-potency anti-psychotic medications as the initial has ability to act and show effect in controlling in mental health disorder compared to the low-potency drugs. The atypical anti-psychotic medications mainly seen to act on the serotine receptors 5-HT2A and 5-HT2C compared to dopamine receptors. The antagonism with 5-HT2A enhances the dopaminergic activity executed in nigrostriatal pathway that leads to reduce the extrapyramidal side-effect liability among the use of atypical anti-psychotic medications (Żołek et al., 2018).

2.4 Concept of Schizophrenia

Schizophrenia is referred to as psychological health condition which usually develops them in the late adolescent or early adulthood stage and negatively impacts speech, emotions, thinking and other areas related to the life of a person's everyday activity and social interaction (Parnas and Zandersen, 2018). It affects nearly 20 million people globally, but it is not considered as one of the common mental disorder that affects people. Schizophrenia does not develop early in men but in women and it leads individuals to develop considerable disability (WHO, 2019). Schizophrenia is a long-term condition which cannot bee cured but with effective treatment the symptom of the disorder can be managed to support enhanced well-being of the patients (WHO, 2019). The people affected by schizophrenia develop delusions and hallucinations which is experiencing situation or condition that are not true or do not exist in the real world (WHO, 2019). As argued by Schultze‐Lutter and Theodoridou (2017), the other symptoms of the disorder include lacking motivation to perform everyday task and self-care, inability to express emotionally, hindered social life and unusual speech and thought patterns that negative affect establishing communication with others. The people affected by schizophrenia are unable to realise that they are unwell, and they feel the delusions as well as hallucinations to be realistic which makes it harder to convince them in taking medication and availing treatment for the health disorder (Schultze‐Lutter and Theodoridou, 2017).

2.5 Factors influencing Schizophrenia

The factors responsible for development of Schizophrenia in adults include presence of genetic inheritance, chemical imbalance in the brain, environmental factor and certain medication or drugs (Stilo and Murray, 2019). In the study by Skene et al. (2018), it is mentioned that no single gene inheritance is identified to be responsible for causing schizophrenia to adults. However, it is considered more likely that different set of genetic combination present in the family when inherited through birth may make the person be at risk of developing the disorder but not specifically indicates that person must develop the disorder. As argued by Haaf et al. (2018), schizophrenia is mentioned to be influenced by imbalance in the chemicals such as glutamate, dopamine and serotonin in the brain. This is because the chemical acts as neurotransmitters to allow messages to be send through nerves in the brain for its effective functioning. In schizophrenia, the medial temporal and prefrontal lobe in the brain is usually damaged which are involved with managing working and declarative memory (Shah and González-Maeso, 2019). The study by Bator et al. (2018) argues that environmental condition such as extreme stress, victimisation, social isolation, childhood trauma and others influence development of schizophrenia apart from genetic factors. This is because such environmental condition leads to influence the brain functioning in a hindered way leading to development of psychotic symptoms of schizophrenia among individuals (Bator et al., 2018).

2.6 Model and Theory regarding Schizophrenia

The Cognitive Model of Psychology informs the way thoughts and perception of the individuals influence their lives (Beck et al., 2019). According to the Model, complex environmental, behavioural, neurobiological and cognitive factors are responsible for raising diverse symptomology in people with schizophrenia. The theoretical construct of the model mentions that impaired integrative performance of the brain along with domain-specific deficit in cognitive condition enhances the vulnerability to experience adverse experiences in life that may lead to dysfunctional behaviour and beliefs (Beck et al., 2019). However, the symptoms regarding disorganisation do not develop from specified neurocognitive deficits butt from the paucity of available resources needed for maintaining adherence to set rules of communication. It is argued by Beck et al. (2019) that the delusions in life of schizophrenic patients according to the Cognitive Model of Psychology are analysed through the interplay between cognitive biases and resource-sparing strategies and mentioned to be developed due to biased data regarding information processing. In contrast, the Theory of Mind informs that having effective mental state is one of the founding elements of social elements for social interaction and prediction as well as interaction regarding the behaviour of others (Firth, 2015). In the study of Firth (2015), it is mentioned that some of the schizophrenia patients instead of considering belief as the subjective representation of reality equate it with the representation of the belief as reality. This may lead them to develop difficulty to differentiate between objectivity and subjectivity and orient to maintain false belief in delusional convictions. In addition, neglecting the social sign and putative intentions may develop communication breakdown and disoriented thoughts. Moreover, schizophrenic patients may express difficulty in experiencing different behaviour due to their personal intentions to be considered by them being under the control of alien individual. This led Firth (2015) to determine compromised theory of mind (ToM) exist for schizophrenia patients which are responsible for the disordered willed action, hindered self-monitoring and disoriented intension and thoughts. The study by Firth (2015) mentioned that the patients with schizophrenia express different ToM ability which depends on the prevailing of subjective or objective emotions in them. The schizophrenic individuals with expressed disorganized and negative behavioural symptoms would show impaired ToM performance which may be similar to people affected by autism due to their incapability to understand and act in all mental state. The paranoid schizophrenic patients are considered to perform ineffectively in controlling themselves but are found to have intact ToM in understanding mental state (Firth, 2015).

2.7 Impact of anti-psychotic medication in adults with Schizophrenia

The common side-effects of anti-psychotic medications in adults with schizophrenia include sedation, headaches, diarrhoea, anxiety, headaches and others (Stroup and Gray, 2018). As argued by Stroup and Gray (2018), the extrapyramidal side-effects include dystonia which is abnormal muscle functioning, akathisia which is distressing sense of restlessness from the inner feeling and Pseudoparkinsonism which is tremulousness and drooling feeling among individuals similar to Parkinson’s disease. The other side-effect includes orthostatic hypotension, blurred vision, constipation, reduced respiration and dry mouth (Stroup and Gray, 2018). It is argued by Stroup and Gray (2018), the anti-psychotic medications use may lead to development of tardive dyskinesia which is frequently developed on use of high-potency anti-psychotic medications like haloperidol. It characterises reduced, repetitive, purposeless and involuntary movement that leads the patients to avoid treatment through the use of medication out of the side-effects (Stroup and Gray, 2018). The uncommon side-effects seen in people using anti-psychotic medications are blood dyscrasias commonly found on the use of clozapine, metabolic syndrome such as diabetes, high serum triglyceraldehydes, high-density lipoprotein, obesity and others (Dikeç et al., 2018). The neuroleptic malignant syndrome which is fatal condition and characterised by hyperthermia, muscle rigidity, laboratory anonymities and others are seen to be caused by the use of anti-psychotic medications as side-effect (Dikeç et al., 2018).

2.8 Gaps in Literature

The existing literature provides overview regarding the anti-psychotic medications and schizophrenia in adults along with the way they are inter-related and helps in treatment of adults with the mental disorder. However, the literature lack information regarding which specific metabolic side-effects are mostly faced with the use of anti-psychotic medications on individuals with schizophrenia. The literature lacks to mention in detail the rate of impact of the metabolic effects on schizophrenia patients and factors which instigates the development of metabolic effect on the use of anti-psychotic medications in schizophrenia. Moreover, the management strategies to overcome the adverse metabolic impact on the use of anti-psychotic medications is not mentioned. Thus, to further explore these gaps and resolve them, the current study is been developed.

Chapter 3: Methodology

3.1 Research Design

The research design to be used in framing the study is a systematic review. The systematic review is referred to the review of well-formulated research question by using systematic and reproducible methods for identifying, selecting and critically appraising all relevant research and to gather and analyse data from existing studies (Munn et al., 2018). The systematic review is to be performed as it allows the development of clarified and comprehensive overview regarding the stud topic (Elliott et al., 2017). This indicates that following systematic review would help in the study to gather comprehensive data regarding metabolic impact of anti-psychotic medication to understand the way and the mechanism through which they affect schizophrenia patients. The systematic review helps in highlighting the methodological concerns faced in the existing studies which are to be improved in future work (Elliott et al., 2017). Thus, the validity of the studies selected for the critical appraisal can be determined. The systematic review also helps in retrieving effective evidence to methodically provided answers to the raised question in the study (Elliott et al., 2017). However. the narrative review is not to be used because they often fail to meet the essential criteria that are important for assisting in mitigating bias in the study. They lack explicit information of the criteria for the selection of articles and leads to hindered evaluation and examination of article which causes inappropriate retrieval of results and findings to be presented in the study (Cena et al., 2019). Moreover, narrative review requires an increased amount of time and resources in framing the study and thus is not to be used (Cena et al., 2019).

3.2 Search Strategy

The electronic search strategy is to be mainly used in framing the study. This is because electronic search is time-saving and cost-effective as most of the articles are found easily with the use of specific keywords and are freely accessible with few being needed to be paid to get access. Moreover, the electronic search helps to overcome geographical barrier to get access to the wide number of health-related article and journals published globally regarding any topic of intertest (Jin et al., 2020). The offline search is also to be used so that physically the available data regarding the topic can be evaluated to develop written data which may help in enhanced understanding of the online information gathered regarding the topic. The electronic search is to be executed by using databases such as CINHAL and MEDLINE. The CINHAL database is to be used because links to wide number of full-test articles and journal are directly revealed from which required data can be collecting in framing the study. Moreover, it allows better search results regarding study topic to be performed by limiting the number of irrelevant articles to be showcased. The MEDLINE is to be used because it provides full-text journal and articles that are ethically published and show credibility in presentation of the results of the topic. The Keywords to be used in framing the search are “Metabolic effect”, “Schizophrenia”, “Anti-psychotic medication”, “adult weight gain in schizophrenia”, “diabetes in schizophrenia”, “lipidemic in schizophrenia” and others. The Boolean operators AND and OR are to be used in connecting the search terms so that meaningful results can be gathered.

3.3 Inclusion and Exclusion criteria

The inclusion criteria are referred to the characteristics that are determined to be included and present in the study as they are the relevant factors that have been focused in the study and avoiding including them would lead to raising error in the research (Gregory et al., 2017). However, the exclusion criteria are the rejected characteristics in the study that are considered not to be specially included in the research as it would lead to divert the topic and make the researcher fail to meet the aim of the study or resolve the raided question in the study by presenting valued and effective information (Krynicki et al., 2018). The inclusion criteria to be followed in the study are articles published on and between 2013-2020, written in English, contains data regrading metabolic effects of anti-psychotic medication used in schizophrenia adult patients, contains primary quantitative data, academic and fully-accessible. The exclusion criteria in the study are articles published before 2013, written in other language expect English, non-academic, only abstract is available, contains data regarding schizophrenia children and contains secondary data. The articles published within the last 7 years is been included in framing the study because they contain updated information regarding any experimentation and scientific data related to support understanding of anti-psychotic medication metabolic effect on patients with schizophrenia. The articles published before 2013 is not to be used as they contained backdated information that may be made obsolete or unacceptable by the new experimental results found regarding the topic. The articles written in English are to be specifically included as they contain information in English language which is well-understood by the current researchers who belong from the UK where the key language understood and spoke is English. The articles written in other language is to be excluded as the contain information in language that cannot be interpreted by the researcher to gather valuable data present in them to be later informed in enriched execution of this research. The articles containing primary quantitative articles are to be included in the study because it contains information that are directly collected through experiment from the participants and not been manipulated by the personal beliefs and thinking of the researcher during presentation. The secondary articles are avoided to be used as they contain the data which are interpreted by the personal thoughts and thinking of the researcher that may have led to wrong presentation of data which is diverted from the original thinking mentioned by the participants. The academic articles are to be used as they are found to contain credible data which are supported by experimental and logical data in the study. The non-academic articles are mainly grey literature that fail to provide in-depth focus regarding the study through analytical scientific evidence and information. The fully-accessible articles are to be included in the study because they contain detailed information to be explored for presentation in the research. The articles related to schizophrenia in adults are to be considered and children are to be avoided as it would help to gather information based on the raised question and focus of the study.

3.4 Critical Appraisal of Articles

The critical appraisal of the articles is to be made by following Caldwell’s critical appraisal framework. This is because it helps to execute detailed analysis of quantitative articles which lower the burden on the researcher to determine the validity and credibility of the articles to be used in framing the study (Ribeiro et al., 2018). Moreover, it is to be used as it helps in gathering high-end quality research information for enriched execution of any research topic (Ribeiro et al., 2018). The use of framework does not require any special knowledge and contains flowchart of questions that can be easily followed in framing the critical appraisal of selected articles.

3.5 Data Analysis

The data analysis is the process of evaluating, examining, transforming and modelling data with the key goal of discovering the useful data and framing supporting decision-making in the study (Riebschleger et al., 2017). The thematic analysis is to be used as the data analysis framework in the research. The thematic analysis is to be used because it provides increased flexibility to the researcher to modify the data according to the need of the research and provide detailed and enriched account of information in the study (Roberts et al., 2018). The other benefit of using thematic analysis is that it allows to present larger set of data in a systematic way to assist in resolving the raised question in the study. Moreover, it assists in framing well-defined themes to methodically present information in the study and allow multiple theories to be inter-linked across different epistemologies (Roberts et al., 2018). In developing the thematic analysis, initially the gathered data is to be explored and evaluated to determine the specific themes to be framed in presenting the information. The developed themes are to be reviewed and the data are to be separately presented in them to avoid any duplication of information.

3.6 Ethical Considerations

The ethical consideration in the study is to be followed so that no legal actions are faced and morality in the study is ensured. The data to be shared are to be appropriately referenced with the author name and dates so that plagiarism can be avoided. The information is to be paraphrased and presented according to the themes. The personal information of the participants if shared unethically in any studies are to be rejected to be used or presented in the study.

Chapter 4: Results and Discussions

4.1 Results and Findings

Theme 1: Impact of different antipsychotic medication use on weight gain and other metabolism of adults with schizophrenia

The weight gain is one of the adverse metabolic effects of anti-psychotic medication and studies are being explored to understand to the extent they influence schizophrenia patients. The study by Pérez-Iglesias et al. (2014) mentioned that the key aim of the study is to examine the course of weight gain and incidence of metabolic abnormalities in the first 3 years of anti-psychotic intervention for schizophrenia adults. The study used quantitative research design in framing the research and clinical assessment was executed to determine the changes overtime regarding metabolic impact of anti-psychotic medication. For this purpose, the study included 170 patients with first-episode of psychosis symptoms in schizophrenia. The patients were randomly and flexibly administered olanzapine (32%), risperidone (36%) and haloperidol (32%) anti-psychotic medications. The results revealed that the mean increase in body weight over the 3 year of anti-psychotic medication use is 12.1 kg. The 85% of the mean body weight was seen to be raised as a result of metabolic impact of the medication within the 1 year of administration to the patients. The total LDL cholesterol and triglyceride also followed similar trajectory and 121.9 by the 1 year of administration of the medication. It led to conclude that the first year of the intervention of anti-psychotic medication is critical to create metabolic impact on the body towards support increased body weight and associated factors. The strength of the study is that it was one of the longest follow-up cohort study regarding first-episode of psychosis in schizophrenia patients. The limitation of the study is that adherence of the medication was reported personally by patients that may have led to collection of over-estimated results. The other limitation is that the sample size is comparatively small due to generalisation of the results could not be reached. In the study by Matei et al. (2016), the aim is to evaluate the rate of weight gain in patients with first-episode of schizophrenia caused by application of anti-psychotic medication. The study design included analysis of the weight gain related to typical and atypical anti-psychotic medication which is used in the European First-Episode Schizophrenia Trial (EUFEST) study. For this purpose, 113 patients with first-episode of schizophrenia is selected and their weight is assessed. They were provided five anti-psychotic medication namely Ziprasidone, Olanzapine, Amisulpride and Quetiapine as atypical and Haloperidol as typical anti-psychotic for 9 to 12 months. The results revealed that no statistically significant changes were seen in the groups those were provided atypical and typical anti-psychotic medication. The weight gain is mentioned to be highest within first 3 months of the initiation of the anti-psychotic medication in 57.49% patients. The lowest weight gain was observed in people who were provided ziprasidone (3.87 kg) and highest weight gain that is 9.83 kg has been seen in patients who were administered olanzapine as anti-psychotic medication. The limitation of the study is that the sample size is small, and the patients were neuroleptic-naïve that led to avoid generalisation of the results who were suffering from chronic disease. In contrast, the study by Tandon et al. (2020) aimed to analyse the impact of second-generation anti-psychotic medication as treatment intervention for schizophrenia patients on their quality of life and everyday functioning. The study is cross-sectional web-based survey in which responses from the schizophrenia patients from world-wide are accessed to understand the side-effects faced by them on using the second-generation anti-psychotic medications. The survey data is gathered from Denmark, Italy, Norway, Canada, Spain, Australia, United States and Spain. In total, 435 participants are recruited based on the inclusion and exclusion criteria. The use of Glasgow Antipsychotic Side-Effect Scale (GASS), sociodemographic and clinical questions and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) are used in gathering and analysing data. The results revealed that the participants mentioned to develop medium satisfaction in their quality of life on using secondary anti-psychotic medication for schizophrenia. It is mentioned that 52.4% expressed facing increased body weight as a result of use of the second-generation medications. The other side-effects faced by them are insomnia (74.7%), sleeping during the day (83.2%), problem with sexual activity (53.4%) and dry mouth (63.9%). The strength of the study was that it helped in gathering effective insight regarding patient perspective of side-effects of anti-psychotic medication use in schizophrenia. The limitation faced in the study is that the patient survey led the researcher to be reliant on gathering self-reported patient criticism of the side-effects of medication which may be presented by them in manipulated manner causing error in the study.

In another study by Bazo-Alvarez et al. (2020), the aim was to determine the long-term impact of anti-psychotic medication on the body weight of the patients suffering from schizophrenia and other mental disorder like bipolar disorder, psychosis and others. The article used population-based cohort study design in framing the research. In between 2005 and 2015 in the UK primary care, the data is gathered regarding the impact of olanzapine, quetiapine or risperidone on weight of the patients. In the study, total of 22,306 women and 16,559 men were included who were treated with different first-generation anti-psychotic medication. The results revealed that Olanzapine compared to other anti-psychotic medication are involved in contributing the highest weight gain among patients. On four-year study, it was revealed that more than 5 mg of olanzapine contributed to 6.1 kg weight gain among the women and more than 4.4kg weight gain among the men. The weight gain was seen to be exponentially increased with higher dose use of anti-psychotic medication by the patients. The strength of the study is that it used a large sample size and performed follow-up study due to which the clinical effects of anti-psychotic medication use are effectively understood and study results could be generalised. The limitation of the study is that only impact of first prescribed drugs are determined whereas the secondary care service impact that may have also influenced the metabolic effect on the patient to express increased body weight are neglected.

Theme 2: Impact of different antipsychotic medication use on blood glucose of adults with schizophrenia

The presence of hyperglycaemia or diabetes is another key metabolic impact seen in schizophrenic patient on use of anti-psychotic medication and studies are to be explored to understand the extent to which it affects the people. In this purpose, the study by Annamalai et al. (2017) is included which aimed to compare the prevalence of diabetes in patient suffering from schizophrenia who are treated with anti-psychotic medication in community mental health centre and metropolitan area. The study was a quantitative research and the researcher reviewed the psychiatric notes of patient with schizophrenia in gathering data. A total of 326 patients with schizophrenia along with 1899 patients as control group are included in the study. The results revealed that patient suffering from schizophrenia in both care condition expressed higher affinity to show increased BMI rate compared to the control population (32.11, SD = 7.72 vs 27.62, SD = 5.93). The study also revealed that 23.9% of the patient with schizophrenia reported showing suffering from diabetes as a side-effect from the anti-psychotic medication use compared to 12.2% of the patients in control group. On control for sex and age, it was revealed that patients with schizophrenia show increased risk of development of diabetes (OR = 2.42, P = 0.000). The limitation of the study is that the data was collected in self-reported manner due to which the authenticity of the gathered response cannot be ensured. The other limitation is that the study is not controlled due to which the demographic variables were highly different in control and experimental groups. In comparison, the study by Ingimarsson et al. (2017), the key aim is to determine the prevalence of high blood glucose, dyslipidemia and type-2 diabetes in relation with the use of clozapine or other antipsychotics for patients with schizophrenia. The study is ongoing research for psychotic disorders in the Department of Psychiatry at Landspitali University Hospital (LUH). The study included 188 participants who were treated with clozapine and 395 patients who were not or never treated with the use of clozapine. The data were collected regarding HbA1c, blood glucose level and blood lipid levels. The results revealed that males who were administered clozapine were 2.3 times more likely whereas females who were treated with clozapine were 4.4 times more likely to be suffering from type-2 diabetes. The Triglyceride level was found to higher in the experimental group compared to the control groups. The limitation of the study is that it is a retrospective comparative analysis study which is collected from a single location due to which the results are unable to be generalised. Moreover, the medical data used in developing the information were not complete due to which error in the determination of the side-effect of clozapine may be faced. In similar to the previous study, the study by Wani et al. (2015) aimed to determine prevalence of diabetes dysregulation in schizophrenia patients before and after the treatment with different anti-psychotic medication. The study used quantitative research design in formulating the research. In the study, 50 patients were recruited through determination of their schizophrenic state by using DSM-IV. In order to determine the glucose dysregulation among the patients, glucose tolerance test before and after anti-psychotic treatment is executed. The results in the study are interpreted by considering the criteria mentioned by the American Diabetic Association. The age and sex specific match subjects were considered for comparison in the study. The results revealed that glycaemic state of the patient group, when compared with the control group, revealed that initially glucose level was stable, but the anti-psychotic medication treatment resulted in glucose dysregulation among the patients. The initial 6 weeks examination of glucose level revealed that it is worsened in all patients who were administered antipsychotic medication with the most increase in blood glucose level is seen who were administered olanzapine on completion of the study at the end of the 14th week. The strength of the study is that it mentioned which among the anti-psychotic medications is more effective in resulting adverse metabolic impact on the health of schizophrenia patients. However, the limitation of the study is that the sample size is small due to which generalisation of the results could not be reached.

The study by Sugai et al. (2016) aimed to determine the prevalence of obesity, hyperlipidemia, hypertension and diabetes mellitus in outpatient and inpatients with schizophrenia due to use of anti-psychotic medication. The study for the purpose performed large-scale intervention by using a questionnaire in the 520 outpatients and 247 inpatients facilities of the Japan Psychiatric Hospitals Association. The data was collected between January 2012 and July 2013. A total of 15,461 inpatients and 7,655 outpatients with schizophrenia are involved in the study. The results revealed that outpatients expressed increased prevalence of diabetes mellitus along with hypertension, obesity, hyperlidepmia and others compared to the inpatients. The hypo-HDL cholesterolemia is found to be present in higher quantity in the inpatients compared to the outpatients. The age-specific analysis revealed that 2 to 3 times increased diabetes mellitus along with hypertension, obesity, hyperlidepmia are seen in outpatients compared to the inpatients. The limitation of the study is that it performed cross-sectional survey due to which duration of the impact of the antipsychotic medication on influencing diabetes and others could not be identified in the schizophrenia patients.

Theme 3: Factors related to metabolic impact after use of antipsychotic medication in adults with schizophrenia

The reason and factors related to the development of metabolic impact of use of antipsychotic among the schizophrenia are required to be understood. For this purpose, the study by Song et al. (2014) aimed to determine the relationship between FTO gene with the drug-induced obesity and weight gain among the schizophrenia patients. The study used quantitative research design and included 250 patients with first-episode of schizophrenia who were treated with anti-psychotic medication. The four single nucleotide polymorphisms (SNPs) (rs9939609, rs8050136, rs1421085 and rs9930506) genotype of the patients were identified by using direct sequencing and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The body weight and BMI rate of the patient is calculated at the baseline and at 6 months of administration of risperidone. The results mentioned that at the baseline, the BMI and body weight of the patients were low who were TT homozygotes compared to the patients who were A allele carrier. On 6months administration of risperidone to the schizophrenia patients, it was seen that the BMI rate and body weight of the patients with TT homozygotes are lower compared to the patients who were A allele carriers in rs9939609. The control of age, illness and gender with the G allele carriers were found to have higher body weight compared to the patient with A allele carriers. It led to conclude that FTO polymorphism mainly rs9939609 is related with supporting weight gain among schizophrenia patients after treatment with risperidone. The limitation of the study is that the sample is small size is small due to which wider data are not present to effectively prove the findings developed. The other limitation is that patients were administered other antipsychotics were not included due to which it cannot be holistically mentioned that FDTO gene polymorphism is responsible in supporting the anti-psychotic induced weight gain in schizophrenia patients. The study by Nielsen et al. (2016) aimed to investigate whether reward anticipation is related with amisulpride-induced change in weight among the antipsychotic-naive patients suffering from schizophrenia during initial treatment and after treatment. The study used quantitative research design and recruited 69 schizophrenic patients who were on amisulpride as antipsychotic. The functional magnetic resonance imaging (fMRI) was done on 58 patients when they were performing a monetary reward task and after 6weeks of treatment with amisulpride, a second fMRI was done on 39 patients to determine the change in their body weight. The results revealed that out of 69 patients, 39 were involved in fMRI follow-up and weight measurement study. The mean dose of amisulpride was 272 which contributed to mean increase of 2.3 kg body weight among the patients. An improvement was seen from the baseline to the follow-up stage in relation to scores on positive and negative syndrome scale. At the end of 6 weeks, the weight gain is found to be related with increased reward activity in the same region during treatment. It led to conclude that activity in the striatal region of the reward system are found to be related with individual variability in antipsychotic-related weight gain. The limitation experienced in the study was that the reward was not food-related but money-related due to which the way food-related would impact in anti-psychotic related weight gain among schizophrenia patients in unable to be understood. The study by Montastruc et al. (2015) mentioned that it aims to determine the pharmacodynamic mechanism of diabetes induced by intake of anti-psychotic drugs by the schizophrenia patients. The study design mentioned used of logistic regression and analysis to determine the relation between the receptor occupancies by antipsychotics and Individual Case Safety Reports (ICSRs). The data are mainly collected from the VigiBase from 01/01/1994 to 29/03/2013 entered by the ICSRs. In the study, the potential relation between the antipsychotics' receptor occupancy and report of diabetes in schizophrenia patients with antipsychotic medication use are determined.

The results revealed that Clozapine was the key antipsychotic medication that is responsible in raising risk of diabetes among patients. A statistically significant and positive relation was found to be present between muscarinic M3, histamine H1, serotonin 5-HT2C and 5-HT2A receptor with the development of diabetes in schizophrenia patients using anti-psychotic medication. Moreover, a multivariate regression model mentions that histamine H1 (AOR=1.91, CI 95% 1.38–2.64) and serotonin 5-HT2c (AOR=2.13, CI 95% 1.72–2.64) are key indicator of presence of risk of diabetes among the patient using anti-psychotic medication. This indicates histamine H1 and serotonin 5-HT2C receptors are responsible for anti-psychotic induced diabetes in schizophrenia patients. The limitation of the study is under-reporting of data regarding the mechanism of action of different anti-psychotic in influencing risk of diabetes among patients who are involved in its use.

Theme 4: Strategies to overcome metabolic effect of antipsychotic medication in adults with schizophrenia

The metabolic effect caused by the antipsychotic medication use negatively affects the quality of life and living of the schizophrenia patients. Therefore, strategies are to be identified in overcoming their impact so that solutions can be determined to ensure better quality of the patient. The study by Correll et al. (2020) aimed to determine the impact of olanzapine accompanied with the administration samidorphan for managing weight gain in schizophrenia patients out of anti-psychotic medication use in treatment. The study used quantitative random research design and they randomly assigned 561 schizophrenia patients to receive olanzapine treatment combination treatment with olanzapine and samidorphan for 24-weeks. The results revealed that out of 561 patients, 280 were provided combination of the medications and the rest 281 were provided only olanzapine. At the end of 24-weeks, the olanzapine/samidorphan group shows weight change by 4.21% from the baseline and 6.59% change in body weight who were in the olanzapine group. This indicates significant lesser weight gain by the olanzapine/samidorphan group compared to the olanzapine group. The increase in the waist circumference was seen more in the olanzapine group compared to the olanzapine/samidorphan group. The improvement in schizophrenia symptoms was similar in both the groups. The limitation of the study is that nearly 40% of the patient at the beginning of the study avoided to involve that resulted in huge loss of data collection in the study. The other limitation is that the data collected was based on self-report by the patients due to which error may be raised if they reported the data in manipulated way. The study by Usher et al. (2013) aimed to examine the impact of nurse-led intervention regarding weight gain management in people with schizophrenia along with other serious mental illness and taking second generation antipsychotic medication. The study design is experimental randomised control trial. The control group in the study were provided a 12-week healthy lifestyle booklet to be followed which was also provided to the intervention group. Moreover, the intervention group were provided weekly nutrition education, exercise education, nurse support and exercise support apart from the booklet. A total of 121 participants were included in the study out of which 50 participants were randomly recruited in the control group and 51 participants were recruited to the intervention group. The results revealed that reduction in mean weight by 0.74 kg is reported at the end of 12 weeks among the intervention group while only 0.17 mean reduction in weight was reported in case of the control. The limitation faced in the study was that the participant was not blinded as they were aware of which they are been allocated and the differences in treatment to be received by them. This may have negatively influenced the authenticated gathering of responses regarding the impact of nurse-led weight management impact on mentally ill patients who had weight gain induced by antipsychotic medication use. The study by Wu et al. (2016) mentioned to determine the impact of Metformin in in treatment of metabolic effect caused by antipsychotic medication use by schizophrenia patients. The study design used in randomised controlled study and a total of 201 schizophrenia patients are involve in the study. The patients included were seen to be suffering from dyslipidaemia, insulin resistance and weight gain. The metformin was provided for 24 weeks to the patients and baseline data were evaluated at 12 and 24 weeks. The primary outcome revealed that low-density lipoprotein cholesterol (LDL-C) levels after the treatment of metformin among the experimental group reduced by 3.37 mmol l–1 compared to 1.02 mmol l–1 decrease in the placebo group. The metformin treatment was found to cause reduction in insulin resistance index, body weight, insulin and total cholesterol and triglyceride. The improvement in weight and insulin resistance could be seen at the end od 12-weeks but the reduction in LDL-C level is seen at the end of 24 weeks. The limitation of the study is that separately the impact of metformin use in each drug induced dyslipidaemia and weight in schizophrenia patients is not evaluated to determine to way it impact in different antipsychotic medication use.

4.2 Discussion

The study mainly investigated concept and way antipsychotic medication induces metabolic impact among adults suffering from schizophrenia. This is because with the first episode of schizophrenia, the patients do not express risk of metabolic disorder such a weight gain, lipidemic, diabetes and others. They are seen to develop later in the course of treatment of schizophrenia regarding which analysis is effectively required to understand relation of metabolic effect and antipsychotic use among the patient in gathering valuable and informative data to support better quality life and health of schizophrenic patients. The studies by Pérez-Iglesias et al. (2014), Matei et al. (2016), Tandon et al. (2020) and Bazo-Alvarez et al. (2020) mentioned that one of the key metabolic effect by antipsychotic medication use among schizophrenic patients is weight gain. This is evident as in all these studies statistically significant weight gain post-baseline is seen in schizophrenic patients who were provided antipsychotics. The analysis of the studies Pérez-Iglesias et al. (2014) and Bazo-Alvarez et al. (2020) revealed that Olanzapine is the antipsychotic that contributed in supporting increased weight gain in schizophrenia patients compared to the use of other antipsychotic medication such as risperidone, haloperidol, ziprasidone, amisulpride and quetiapine. This is because of increased dose of its usage and mechanism of action in controlling the health disorder (Song et al., 2014). The fact is supported by existing studies by Huang et al. (2020), Okazaki et al. (2017) and Pełka-Wysiecka et al. (2019) indicating Olanzapine dose to be controlled as they are key contributor in increased metabolic weight gain among the schizophrenia patients that compromises their quality of life in negative manner. In contrast, the other two studies of Matei et al. (2016) and Tandon et al. (2020) does not specifically mention which antipsychotic in particular are considered to contribute increasingly in supporting more weight gain among schizophrenia patients. The studies Pérez-Iglesias et al. (2014), Matei et al. (2016), Tandon et al. (2020) and Bazo-Alvarez et al. (2020) also revealed that higher the dose of antipsychotic, increased weight gain is experienced by schizophrenia patients. This indicates that the adults with schizophrenia in worsened stage are prone to develop higher weight gain as a metabolic effect of the medication as they are the ones who were provided high dose of the medication in controlling the symptoms regarding the disorder. The second-generation as well as first-generation antipsychotic are equally effective in causing weight gain among the schizophrenia adults who are using them for their treatment of the disorder. The study by Pérez-Iglesias et al. (2014) highlighted that most weight gain due to effect of antipsychotic use by schizophrenia patients is seen within 1 year whereas the study by Matei et al. (2016) mentioned the highest effect is seen within first 3 months. In comparison to the other studies, the study by Bazo-Alvarez et al. (2020) only mentioned gender specific metabolic effect of weight gain among schizophrenia patient due to use of antipsychotics. The study mentioned that more weight gain due to antipsychotic medication use is seen in women compared to men. However, there is lack of evidence found from other studies to prove this context. The exploration of studies further mentioned that hyperglycaemia or diabetes is another major metabolic impact created by antipsychotic use among schizophrenia patients. The studies by Annamalai et al. (2017), Ingimarsson et al. (2017), Wani et al. (2015) and Sugai et al. (2016) all expressed statistically significant data indicating development of diabetes as metabolic effect induced by the use of antipsychotic in schizophrenia adults. The study by Ingimarsson et al. (2017) identified clozapine use as the most effective antipsychotic medication in raising risk of diabetes or hyperglycaemia in schizophrenia patients. In contrast, the study by Wani et al. (2015) identified olanzapine to be key antipsychotic that led to raise risk of increased blood sugar in schizophrenia patient who do not have any previous indication of presence of diabetes. The fact is also supported by the study of Corele et al. (2020) who mentioned single use of olanzapine creates more adverse metabolic effect to the schizophrenia patient which lead them to be at increased risk of developing diabetes compared to schizophrenia patients who are on other antipsychotic or combined therapy for olanzapine. The gender differences are seen to be associated with development risk of diabetes, dyslipidaemia and others as metabolic effect from the use of antipsychotics. This is evident as the study by Ingimarsson et al. (2017) mentioned females are more prone to develop metabolic disorder of obesity, diabetes and hyperlipidaemia who are schizophrenic and are on anti-psychotic medication. In contrast, the study by Sugai et al. (2016) highlighted that the males are at slightly greater risk compared to females in develop of diabetes as a result of metabolic effect induce by antipsychotics use in schizophrenia. One of the study of Ingimarsson et al. (2017 being ongoing research and Sugai et al. (2016) a cross-section research, there is limitation of presence of adequate follow-up data to prove the context. Therefore, further examination is required in gender-specific issues in schizophrenia patient with use of antipsychotic regarding metabolic effect. The metabolic effect caused by antipsychotic use in schizophrenia adults are required to have some moderating factors and condition influencing the effect. In this context, the study by Song et al. (2014) is been analysed which revealed that four fat-mass and obesity-associated (FTO) gene SNPs (single nucleotide polymorphisms (SNPs rs9939609, rs8050136, rs1421085 and rs9930506) may be reason behind the metabolic effect of weight gain caused by antipsychotics use. The study is first research to relate the specific FTO for weight gain in schizophrenia patients taking antipsychotics. The previous studies by McCaffery et al. (2013) and Dlouhá and Hubáček (2012) have separately mentioned the different FTO genes influenced by anti-psychotic use to cause weight gain in schizophrenia patients. However, the study fail to mention the mechanism followed by the antipsychotic in affecting FTO towrads supporting expression of weight gain the schizophrenia patients.

The study by Nielsen et al. (2016) mentioned that attenuated fMRI reward activation in individuals prior the initiation of antipsychotic treatment in schizophrenia patients is considered to support weight gain in them with the use of the medication. This is because it instigates them to intake more food and increased dose of the medication thinking it would help them more effectively overcome the psychological health condition. Thus, it can be determined that reward activity and FTO genes play a key role in supporting antipsychotic-induced weight gain. In contrast, the study by Montastruc et al. (2015) mentioned that hindered histamine H1, serotonin 5-HT2C and 5-HT2A receptor expression leads to development of risk of diabetes in schizophrenia patient using anti-psychotic medication. The mentioned fact is true as serotonin controls the release of insulin in the body that is the key contributor in managing blood sugar level in patients (Martin et al., 2019). Moreover, histamine play a key role in glucose metabolism in the body and therefore its expression by the influence of anti-psychotic medication indicate it to play a key role in raising blood sugar level in schizophrenia patients (Misto et al., 2019). The studies focussed to explain few strategies in which antipsychotic induced weight gain and diabetes as metabolic impact on the schizophrenia patient can be limited and be able to overcome. The study by Correll et al. (2020) mentioned that olanzapine along with samidorphan as combined antipsychotic therapy is to be used for controlling antipsychotic-induced weight gain. This is evident as previously the studies by Pérez-Iglesias et al. (2014) and Bazo-Alvarez et al. (2020) has already mentioned olanzapine to be key contributor in weight gain when used as single therapy for the schizophrenia patients. The study by Usher et al. (2013) mentioned that nurse-led weight management support are more effective in controlling antipsychotic-induced weight gain in schizophrenia patients rather than only nutrition support advice. This is because the nurses act to educate and extend help to the schizophrenia patients in controlling weight gain. In the other study by Wu et al. (2016), Metformin is mentioned to control obesity and diabetes risk with antipsychotic medication use among the schizophrenia patients. This is evident as the NHS also mentions use of metformin to control risk diabetes and hyperglycaemia in patients as it assists in enhance insulin use by the body to support glucose metabolism (NHS, 2018).

Chapter 5: Conclusion and Recommendation

5.1 Conclusion

The study investigated extent and way of antipsychotic induce metabolic effect mainly weight gain and hyperglycaemia among schizophrenia patients. This is because antipsychotics are the key pharmacological intervention needed to be used for schizophrenia patients in manging the psychological disorder. Thus, understanding of the extent of their metabolic effect on the body of patients would help to determine the need of managing the metabolic impact for the patient. It is mentioned that hindered metabolic effect created by the antipsychotics use in schizophrenia patients leads them to develop lower quality life. This is because increased body weight leads the individuals to be develop obesity which makes them face hindrance in making effective physical movement of the increased weight. Moreover, hyperglycaemia lead the people to develop risk of additional diseases such as cardiovascular disease, high blood pressure, stroke and others that also lower the health living of the patients. The studies on critical analysis revealed that Olanzapine is the antipsychotic that contributed in supporting increased weight gain in schizophrenia patients. The ziprasidone use creates least impact in weight gain in schizophrenia patient. The first- and second-generation antipsychotics are seen to equally induce metabolic effect of weight gain and increased blood sugar in schizophrenia patients. The FTO gene and straited reward system in the brain is seen to act a key factor in supporting antipsychotic-induced weight gain. The serotonin and histamine regulation are the key aspect in antipsychotic-induced hyperglycaemia in schizophrenia patient. The use of nurse-led nutrition support and exercise in weight management could be used and Metformin for controlling blood sugar and Olanzapine accompanied with samidorphan is to be used in controlling weight gain which are metabolic effect expressed by antipsychotics use in schizophrenia patients.

5.2 Recommendations

The recommendation are as follows:

Regular monitoring of health:

The regular medical assessment and monitoring of health of the schizophrenia patients who are on antipsychotics are to be done. This is because it would help the nurses to determine the extent of metabolic impact of the medication on the patients and accordingly develop prior actions in controlling the adverse effect. The monitoring of health is also required to determine the behavioural changes to be promoted in case of schizophrenia patients after they are put on antipsychotics so the metabolic effect of the medication on them can be reduced and controlled.

Modifying lifestyle action:

In order to control metabolic effect induced by antipsychotics, it is recommended that lifestyle changes in schizophrenia patient is to be promoted. They are to be involved in physical activity and mention to take the nutritional content according to their need of the body. The schizophrenia patients are to be influenced to avoid intake of increased fast food and control their lifestyle to be changed in taking healthy food and performing daily exercise. This is because it would help in keeping the blood sugar under control and avoid weight gain.

Pharmacological intervention:

The clinicians are recommended to perform combine use of antipsychotic to limit the increased metabolic impact of antipsychotics that adversely affect physical health of the patients. The dose of antipsychotics provided to the schizophrenic patients are to be analysed and provided in lower amount possible to avoid increased metabolic impact of the medication on the body. The use of diabetes medication is to be made to manage blood sugar that may be raised out of metabolic impact of antipsychotics in schizophrenia patients.

5.3 Application to Practise

The gathered evidence in the study is to be applied in the medical field to make the nurses and clinical aware of the potential impact the different antipsychotic medication administered and prescribed by them to the schizophrenia patients can affect the patients. The face developed in the study would act as evidence for the clinicians and nurses to understand which antipsychotic medication are the most effective in inducing metabolic impact on the patients. Moreover, the fact developed in the study can be implemented in practise to develop action in management of weight gain and hyperglycaemia caused by antipsychotic medication use in schizophrenia patients.

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