Factors that correlate with higher risks of metabolic syndrome and

premature death in people with serious mental illness

Student Name: Rachael Ifeayinchukwu Ajukwu

Student Number: 22020636

Student Cohort: September 2020 cohort

Module Name: Innovations in Evidence-Based Nursing

Module Code: NS607- 22S1UX

Word Count: 8,309

Submission Date: 9th May 2023

Name of Supervisor: Dr Carlyle London

Module Leader: Llewellyn Morgan

Submitted in partial fulfillment of the Bachelor of Science (Hons)

 ACKNOWLEDGEMENT

First and foremost, I thank God the Father, God the Son, and God the Holy Spirit for
the grace and opportunity to do and finish this course; without God, I am powerless. I
would also like to offer my heartfelt gratitude to everyone who has supported and
continues to support me during this academic journey. Special thanks to my wonderful
husband, Alexis Redmond, who is my rock. My heartfelt thanks goes to all of my
Ajukwu and Redmond family members. Thank you also to my outstanding instructors
at BuckinghamShire New University from my first to final year. I would have loved to
list specific names, but I did not want to make the mistake of leaving any out. I am
grateful to you all for influencing me with your knowledge, wisdom, and courage. My
thanks also go to all of my friends and colleagues from the 2020 September cohort,
who have all encouraged me. Thank you to my bosses and colleagues at Northwick
Park Hospital for your support. Pastor Ephraim and Mrs. Olumewo, as well as the
entire congregation of The Stone Church London, for constantly praying for me.
Finally, thank you to my supervisor, Dr. Carlyle London, for his excellent mentoring.
You piqued my curiosity to learn more.

2
 CONTENT PAGE

Table of Contents

ACKNOWLEDGEMENT ______________________________________________ 2

CONTENT PAGE ___________________________________________________ ii

Table of Contents _________________________________________________ ii

List of Tables_____________________________________________________ v

ABSTRACT _______________________________________________________ vi

CHAPTER ONE ____________________________________________________ 1

1.1 Introduction _________________________________________________ 1

1.2 Background _________________________________________________ 2

1.2.1 Metabolic Syndrome _______________________________________ 2

1.3 Rationale: __________________________________________________ 4

CHAPTER TWO ____________________________________________________ 6

2.1 Research Approach ___________________________________________ 6

2.2 PICO Framework _____________________________________________ 7

2.3 Search strategy ______________________________________________ 7

2.3.1 Electronic Database _______________________________________ 7

2.3.2 Search Terms and Boolean Operators _________________________ 8

2.4 Eligibility Criteria _____________________________________________ 9

2.5 Overview Selection process ___________________________________ 10

3
 2.6 Critical Appraisal - Caldwell's Framework (2011) ___________________ 11

2.7 Data Extraction _____________________________________________ 11

2.8 Data Analysis ______________________________________________ 12

CHAPTER THREE _________________________________________________ 13

3.1 Overview __________________________________________________ 13

3.2 Summary of findings _________________________________________ 13

3.3 Quality of included articles _____________________________________ 14

3.4 Thematic Analysis ___________________________________________ 17

3.4.1 Theme 1: Prevalence of Metabolic Syndrome___________________ 18

3.4.2 Theme 2: Sociodemographic Factors Increasing the Risk of MetS ___ 18

3.4.3 Theme 3: Mortality rates among people with SMI diagnosed with or
without Metabolic syndrome. ______________________________________ 19

CHAPTER FOUR __________________________________________________ 21

4.1 Discussions ________________________________________________ 21

4.2 Strength and Limitations ______________________________________ 23

CHAPTER FIVE ___________________________________________________ 26

5.1 Conclusions ________________________________________________ 26

5.2 Recommendations/Implications for Practice _______________________ 27

REFERENCES ____________________________________________________ 28

Appendices_______________________________________________________ 35

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Appendix A: PRISMA Flow Chart ____________________________________ 35

Appendix B: Cadwell et al. (2011) Appraisal Tool ________________________ 36

Appendix C: Summary of included studies _____________________________ 38

5
List of Tables

Table 1: PICO Framework __________________________________________ 14

Table 2: Eligibility Criteria ___________________________________________ 9

6
 ABSTRACT
Background: Individuals suffering from severe mental illness (SMI) usually have poor
physical and mental health. It is generally known that patients suffering from severe
mental illness (SMI) are more likely to develop metabolic syndrome and die
prematurely.
Aim: The review study seeks to explore and examine the factors correlating with a
higher risk of premature death and metabolic syndrome in people with serious mental
illness. It is well established that people with severe mental illness (SMI) are prone to
developing metabolic syndrome and are at increased risk of premature death.
Methods: A comprehensive literature review (ELR) that critically explores the effect of
metabolic syndrome and premature death in people with serious mental illness will be
carried out. An electronic search was undertaken via academic databases accessed
via the university’s digital library on the EBSCOHost platform via MEDLINE Plus,
PubMed, EMBASE and Scopus.

Findings: High Body Mass Index, Abdominal Obesity, and Blood Pressure, and
resting heart rate indicated a significant prevalence of cardiometabolic risk factors.
Conclusion: According to the review, people with SMI have a higher chance of dying
from nonspecific and unexplained causes, suicide, and other less common and
commonly under-reported reasons connected with particular cardiovascular risk
factors. They also have a higher risk of dying earlier than the general population.

CHAPTER ONE
INTRODUCTION
7
1.1 Introduction

People experiencing severe mental illness (SMI) frequently have poor physical and
mental health (Hayes et al., 2017). They frequently develop one or more of these
chronic physical health problems earlier than those without severe mental illness
(Locket et al., 2016; Williams et al., 2019). Several studies have shown that people
with SMI have a higher burden of early cardio-metabolic abnormalities, such as
diabetes, hypertension, hyperlipidemia, and obesity. People with SMI are more likely
to die prematurely due to these physical health issues (Lambert et al., 2022). In
addition, it is well established that people with severe mental illness have a higher risk
of dying prematurely than the general population (Hayes et al., 2017; Public Health
England, 2022). It is predicted that two out of every three deaths among people with
SMI are due to preventable physical illnesses (Walker et al., 2015). According to Public
Health England (2022), an estimated 95 people in England die from severe mental
illness per 100,000 adults. Compared to the general population, they die 10–20 years
earlier (Lui et al. 2017).

Similarly, people with SMI are at an increased risk of developing metabolic syndrome
compared to the general population (Vancampfort et al., 2014). Metabolic syndrome
is the coexistence of at least three of five cardiometabolic abnormalities (Nilsson et
al., 2019). These abnormalities include abdominal obesity, high blood sugar, high
triglyceride levels, low HDL cholesterol, and high blood pressure (Chen et al., 2019;
Padmavati, 2016). It is widespread; around one in four adults in the UK is thought to
have metabolic syndrome. The risk of metabolic syndrome is significantly increased
by severe mental illness, poor lifestyle choices, and antipsychotic drug use. According
to a meta-analysis by Vancampfort et al. (2015), metabolic syndrome is 58 per cent
more prevalent in people with mental health problems than in the general population.
The findings show that they are consistent with a global increase in cardiovascular
mortality risk. It is well established that people with severe mental illness (SMI) are
prone to developing metabolic syndrome and are at increased risk of premature death
(Baxter et al., 2016; Ferns et al., 2018). Studies have indicated that several
multifactorial reasons can contribute to increasing an individual’s risk of exposure to

8
reduced lifespan and/or increased risk of metabolic syndrome (Boreu et al., 2013;
Baxter et al., 2016; Holt et al., 2010).

Therefore, the review study will seek to explore and examine the factors that correlate
with a higher risk of premature death and metabolic syndrome in people with serious
mental illness. It is well established that people with severe mental illness (SMI) are
prone to developing metabolic syndrome and are at increased risk of premature death
(Baxter et al., 2016; Ferns, 2018). To achieve this, a comprehensive literature review
(ELR) that critically explores the effect of metabolic syndrome and premature death in
people with serious mental illness will be carried out. The ELR will demonstrate a
critical understanding of the evidence highlighting factors that correlate with higher
risks of metabolic syndrome and premature death in people with serious mental
illness. This is aimed at effectively assessing current research and evaluating
evidence-based practice. It will be achieved by adopting an appraisal and analytical
approach when applying the research findings in practice. Finally, the paper will put
forward evidence-based recommendations to be adopted for improving the quality of
patient care provided and enhancing the patient outcome for people with serious
mental illness.

1.2 Background
1.2.1 Metabolic Syndrome

According to Baxter et al. (2016), Metabolic Syndrome (MS) is a collection of medical

problems that raises a person's risk of acquiring cardiovascular disease (CVD),
obesity, and type 2 diabetes. People who have SMI have an increased risk of
developing cardiovascular disease (CVD) at an earlier age, and this increased risk has
been attributed, in part, to a high incidence of metabolic syndrome (Ferns, 2018). In
addition, those who are afflicted with severe mental illnesses (SMI), such as
schizophrenia, schizophrenia-like disorders, bipolar disorder, and severe affective
disorders, tend to pass away at a younger age than the general population (Baxter et
al., 2016; Lawrence et al., 2013). These conditions include schizophrenia,
schizophrenia-like disorders, bipolar disorder, and severe affective disorders.

9
According to the findings of a study that was carried out by Public Health England
(2018), residents of the United Kingdom who have been diagnosed with a severe
mental illness have a higher risk of passing away 7-18 years earlier than those who
do not have concerns related to their mental health. According to Nilsson et al.'s
research from 2019, a poor diet, a lack of physical exercise, and inadequate physical
fitness are all aspects of lifestyle that are associated with individual components of the
metabolic syndrome. In theory, it is improbable that metabolic syndrome would
emerge without an unhealthy lifestyle (Fern, 2018). However, in practice, there are
considerable disparities between persons who have metabolic syndrome in terms of
the existence of numerous bad habits. As a consequence of this, it can be challenging
to ascertain which of a person's various options for their way of life is the one that is
most important to that individual.

People who have a severe mental illness (SMI) are known to have a higher chance of
acquiring metabolic syndrome and dying at an earlier age (Baxter et al., 2016; Ferns
et al., 2018). This is something that has been well-established. According to a number
of studies (Boreu et al., 2013; Baxter et al., 2016; Holt et al., 2010), an individual's risk
of exposure to a shorter lifespan and/or higher risk of metabolic syndrome can be
elevated for a number of multifactorial reasons. These factors can contribute to an
individual's increased likelihood of having their lifespan shortened. According to
research conducted by Public Health England (2018), in comparison to the general
population, adults with SMI who have been diagnosed with cardiovascular disease
have an increased risk of death by 198 fatalities for every 100,000 people. This is
important since cardiovascular diseases (CVD) are responsible for the majority of the
physical co-morbidities that are responsible for around sixty per cent of the excess
mortality reported in SMI (Vancampfort et al., 2015). People who have schizophrenia
or bipolar disorder are more likely to have unhealthy lifestyles, take antipsychotic
drugs, and receive less conventional medical care than people without schizophrenia
or bipolar disorder (Baxter et al., 2016; Fern, 2018; Vancampfort et al., 2015). All of
these factors enhance the risk of developing cardiovascular disease in people with
SMI. As a result, the purpose of the review study will be to investigate and investigate
the factors associated with a higher risk of premature death and metabolic syndrome
in individuals who have a significant mental illness.
10
1.3 Rationale:

Excess mortality rate reduced lifespan and increased prevalence of metabolic

syndrome among people with severe mental has been widely reported. However, no
comprehensive information on the high-risk factors that correlate with premature death
and metabolic syndrome among people with severe mental illness is available.
Therefore, the author wants to explore and examine the factors that correlate with a
higher risk of premature death and metabolic syndrome in people with serious mental
illness. It is well established that people with severe mental illness (SMI) are prone to
developing metabolic syndrome and are at increased risk of premature death (Baxter
et al., 2016; Ferns et al., 2018). Studies have indicated that several multifactorial
reasons can contribute to increasing an individual's risk of exposure to reduced
lifespan and/or increased risk of metabolic syndrome (Boreu et al., 2013; Baxter et al.,
2016; Holt et al., 2010). It is significant to carry out an exhaustive review of the
literature on metabolic syndrome and premature deaths in people with serious mental
illness to influence improved and better delivery of care in practice. As a result, the
main aim of this extensive literature review is to investigate the factors that influence
metabolic syndrome and premature death among individuals with serious mental
illness.

1.4 Study Purpose

The research focuses on factors that augment the danger of metabolic syndrome and
untimely death in individuals with severe mental illnesses (SMI). The following sections
go into further depth about the study's purpose:

1.4.1 Research question:

The research question for the study was developed using the PICO framework.

▪ Population (P) – Adult (18 years and above

▪ Intervention/Exposure (I) – Serious mental health illness
▪ Context (C) - Primary care settings
▪ Outcome (O) – metabolic syndrome & premature death

11
Based on the PICO framework, the research question for this comprehensive literature
review study is:

What are the factors that correlate with a higher risk of premature death and metabolic
syndrome in people with serious mental illness (SMI)?

1.4.2 Study aim:

The primary aim of this review study is to explore the high-risk factors associated with
metabolic syndrome and premature death among people with serious mental illness
in the UK. Identify gaps and finally Make recomendatiom

1.4.3 Study objectives:

The specific study objectives for the review study include the following:

I. To identify high-risk factors associated with metabolic syndrome among people

with serious mental illness in the UK.
II. To identify high-risk factors associated with premature death among people
with serious mental illness in the UK.

12
 CHAPTER TWO
METHODOLOGY
2.1 Research Approach

The primary goal of health sciences research is to identify existing litreture, pertinent,
and evidence-based that may be used to enhance health outcomes (Slaterry, Saeri
and Bragge, 2020). Also when doing health-related research, many study designs may
be used, also choosing an appropriate study design is essential to the accomplishment
of any healthcare research ((Flannelly and Jankowski (2014 ) and Parahoo, 2014).
The narrative literature review research design was used as a secondary research
approach for this study. A literature review is doing a thorough search, identifying and
summarising current literature on a specific topic related to health or nursing care
practice (Moule, 2021). The evidence base for clinical decisions and evaluating the
efficacy of currently used interventions in practice is provided by the literature review
methodology used by healthcare researchers (Ellis, 2019; Polit and Beck, 2017).

Futhermore, An extensive literature evaluation will be conducted for this study to

summarise the information from the studies that are included cogently. A
comprehensive literature study is a comprehensive, critical, and unbiased examination
of current knowledge on a particular topic. They contribute to the development of a
theoretical framework and a research topic or context, making them a crucial part of
the research process (Machi and McEvoy, 2016). A review of the current literature will
aid a researcher in detecting patterns and trends in the literature to identify gaps or
inconsistencies in a body of knowledge (Allen, 2017). The study design comprises
collecting relevant literature after a rigorous screening and evaluation process (Liberati
et al., 2009). This study strategy aims to combine existing data to identify knowledge
gaps or provide evidence-based data on the effectiveness of care interventions
(Ranganathan and Aggarwal, 2020). Therefore, this section will meet the criteria
needed to clearly demonstrate the audit trail to the literature search, selection process,
screening, and data extraction procedures.

13
2.2 PICO Framework

It is important to have a clearly stated research question and succinct goals and
objectives for researchers to arrive at a logical and cogent conclusion in literature
review research (Forster and Jewell, 2017). The PICO framework provides the
framework and structure for defining the research and is made up of certain structured
elements, namely, population (P), exposure (E), context (C) and outcome, Eriksen and
Frandsen (2018) Table 1 provides a summary of the PICO framework used for this
comprehensive literature review.

Table 1: PICO Framework

PICO Element Explanation

Population Adults (aged 18 years and above)

Exposure Serious mental illness

Context Primary care settings

Outcome Premature death and metabolic syndrome

2.3 Search strategy

It is essential to use a thorough and methodical search technique while conducting

secondary research, such as an extended literature review, to discover only the
pertinent and related material for the review. This procedure includes identifying
pertinent keywords and search queries and how they are utilised to locate pertinent
research articles. Cooper et al. (2018)

Electronic Database

An electronic search for relevant evidence-based literature will be carried out using
the university’s digital library. This will provide unrestricted access to a variety of
electronic databases that can be used for a robust and comprehensive literature

14
search (Bramer et al., 2017). Oermann et al. (2021) suggested that the quality of
literature used when carrying out a review study is crucial to the validity and reliability
of the study outcomes. This requires searching reliable and credible health and allied
health databases with a strong reputation for providing access to high-impact peer-
reviewed journals (McCann and Polacsek, 2018). Heath et al. (2022) stressed that
health professionals must develop and demonstrate skills in searching for and
retrieving relevant evidence-based literature to be used in practice. Therefore, the
author followed a structured and systematic approach in searching through electronic
databases for research articles included in the study.

Consequently, the electronic search was undertaken via academic databases

accessed via the university’s digital library on the EBSCOHost platform. The electronic
databases used include MEDLINE Plus, PubMed, EMBASE and Scopus.
Furthermore, the snowballing of literature would be considered. The electronic search
will focus on studies published within the last decade between January 2012 and
December 2022. The literature search was conducted in accordance with Preferred
Reporting Items for Systematic Review and Meta-Analysis (PRISMA) approach Page
et al.'s (2021)

2.3.1 Search Terms and Boolean Operators

The appropriate search terms, which were formed by combining pertinent keywords,
were used to carry out the electronic search. The PICO framework's components
served as the inspiration for the keywords. The identified keywords are merged with
the Boolean operators AND/OR To find a thorough selection of pertinent evidence-
based literature (Ferrari, 2015). Finding relevant articles that have been scrutinised
against the predetermined selection criteria requires using the Boolean operators,
which can either broaden or limit the search results.

Therefore, it is essential to use standardised and applicable vocabulary as search

terms when carrying out keyword combinations during the literature search process
(Hartling et al., 2016). This was achieved by using relevant words derived from the
PICO element.

15
The combination of the search terms using the Boolean operators are as follows:
(“metabolic syndrome” OR “cardiovascular risk” OR “premature death”) AND [mortality
OR survival]) AND (Serious Mental Illness OR schizo* OR Depress* OR Bipolar*).
Following the conclusion of the electronic search, the retrieved articles were assessed
against the established selection criteria relevant to the study goal.

2.4 Eligibility Criteria

Unlike other types of reviews, a comprehensive review defines the criteria used to
determine which articles will be included in or omitted from the review (Synder, 2019).
This is termed the selection criteria, and the criteria provide specific indicators that
assist the researcher in locating relevant studies that correspond with the review
study's significant aims and objectives (Nowell et al., 2017). Moreover, using the PICO
elements of the study, a clear and succinct eligibility criterion was constructed. This
was required to ensure the validity of the review's results and recommendations.

The inclusion and exclusion criteria guarantee that pertinent and suitable research
papers are located, accessed, and incorporated into this research study to produce
the best possible results. The guidelines for inclusion and exclusion that directed the
screening of literature for the comprehensive review are shown in Table 2 below.

Table 2: Eligibility Criteria

S/N Inclusion Criteria Exclusion Criteria

I. Adult aged 16 years and above) Below 18 years

II. Participants must be diagnosed with a Participants have other co-morbidities,

serious mental illness.

III. Articles published in the UK Articles published outside the UK

IV. Articles published in the English Language Articles in any other language

V. Articles published in 2012 and onwards Articles published before 2012

VI. Peer-reviewed articles with full-text access Abstract only, not peer-reviewed

16
2.5 Overview Selection process

This aspect of the extended literature review (ELR) study provides an overview of the
literature search process with details of how many research articles were found, the
number of those either included or excluded from the literature review after the
inclusion and exclusion criteria have been applied (Harari et a., 2020).

The chosen electronic databases were extensively searched using the search
parameters described above. Following the search, all research articles that reported
on metabolic syndrome and mortality in people with severe mental health illnesses
were retrieved for other screening processes. The initial search conducted on
electronic databases yielded a research result. The papers were then filtered only to
return those that carried the study on the main topic within the UK. However, the filter
search produced just a few studies on the topic that had been conducted in the United
Kingdom. As a result, the search was expanded to include studies that satisfied the
main selection criteria but also included those done in settings other than the UK. As
a result, the publication or study location was not set as a search parameter, thus
expanding the search outside the United Kingdom to include other developed
countries.

Additionally, all the retrieved papers were screened, and duplicate or overlapping
papers were detected and removed to narrow the articles to only relevant research
studies that aligned with the selection criteria. The screening process yielded a total
of 67 primary research studies. Each research paper was individually reviewed against
the selection criteria, and their relevance to the study aims and objectives, generating
a total of eight primary research articles included in the review study. Finally, a
snowball search of the references of the retrieved research paper was conducted to
identify any relevant articles (NICE, 2018). The snowballing literature yielded one
primary research study. In the end, a total of nine primary research articles were
included in the extended literature review (Appendix A).

17
2.6 Critical Appraisal - Caldwell's Framework (2011)

PRISMA standards were used for carrying out the methodological evaluation of the
nine primary research articles included in the review (Moher et al., 2009). Critical
analysis of research studies is essential for establishing the validity and reliability of
research outcomes or findings (Khan et al., 2011). According to Forster and Jewell
(2017), completing a quality review of these research studies is critical in assessing
the consistency and dependability of the research process. Garrard (2020)
further emphasised the importance of adopting relevant and verified critical appraisal
tools to examine and evaluate research publications for their validity, reliability, and
generalizability. This can help to reduce the danger of bias while also enhancing
trustworthiness and relevance (Nussbaumer-Streit et al., 2016).

As a result, the nine included articles were critically appraised utilising a tool described
by Caldwell, Henshaw, and Taylor (2011). The appraisal tool can be used for both
quantitative and qualitative research, and all the included studies for the extended
review were rated using Caldwell's eighteen-item appraisal criteria (Cadwell et al.,
2011). The appraisal of these included studies provided insight into the quality of the
study, which was determined using a generalised quality score.

2.7 Data Extraction

The quality of the identified research studies was evaluated using a standardised
critical assessment tool. Following the completion of the critical appraisal, key data
from the findings of the included research is extracted and used as a reference point
for the review analysis. Most of the data extraction is done with an organised and
validated chart or sheet, as well as a validated model. The data extraction sheet
comprised author information, location, study design, outcome measures, study’s
strengths and limitations, and main findings. Furthermore, the retrieved data was
utilised to investigate the cardiovascular risk, prevalence rates of metabolic syndrome,
and standardised mortality ratios. The discussed outcome was generated in
accordance with the study's specific aims and objectives.

18
2.8 Data Analysis

There was a thorough evaluation of the literature, and tables with summary findings
for each review outcome were created. A narrative or descriptive approach was used
to discuss the findings presented in the table. The method of data analysis proposed
by Braun and Clarke (2006) was used to achieve this. During this data synthesis
process, the information gathered from the included research will be arranged into
themes based on the results of the review study. This method works well when data
repetitions are coded in accordance with the aims and objectives of the study
(Snilstveit, Oliver, and Vojtkova, 2012).

19
 CHAPTER THREE
FINDINGS
3.1 Overview

The extensive literature search was conducted using the PRISMA protocol for
systematic literature search as described by Moher et al. (2009) and was developed
using the PRISMA flow chart (Appendix A). For this review, nine research articles
were retrieved following an extensive literature search using electronic databases
such as MEDLINE Plus, PubMed, EMBASE and Scopus. The articles were selected
using the predetermined selection criteria and were critically appraised using the
Cadwell et al. (2011) appraisal tool (Appendix B). Therefore, this section discusses
the central themes generated from the findings of the nine included studies.

3.2 Summary of findings

The primary aim of this review study is to explore the high-risk factors associated with
metabolic syndrome and premature death among people with serious mental illness
in the UK. After carrying out an extensive literature search and structure screening
process, nine research articles that met the eligibility criteria were included in the
review study (Das-Munshi et al., 2017; Gardner-Sood et al., 2015; John et al., 2018;
Munshi et al., 2015; Osborn et al., 2015; Rossom et al., 2022; Smith et al., 2020; Tseng
et al., 2020; Williams et al., 2019). The summary of critical information for each
included study is presented in Appendix C.

All included studies adopted a quantitative research approach, with two studies by
Gardner-Sood et al. (2015) and Williams et al. (2019) carrying out a randomised
controlled trial (RCT) study. Similarly, three research articles undertook a prospective
cohort study design for the collection of data (Das-Munshi et al., 2017; John et al.,
2018; Osborn et al., 2015). In addition, three other studies included in the review study
conducted a cross-sectional survey (Munshi et al., 2015; Smith et al., 2020; Tseng et
al., 2020). Finally, one research article by Rossom et al. (2022) carried out a
quantitative descriptive analysis.

20
The location of publication varied, with the majority (six) of the included studies carried
out in the United Kingdom (Das-Munshi et al., 2017; Gardner-Sood et al., 2015; John
et al., 2018; Osborn et al., 2015; Smith et al. 2020; Williams et al., 2019). Munshi et
al. (2015) conducted their research study in Canada, while Rossom et al. (2022)
carried out a quantitative analysis with data collected from the patient cohorts in the
United States. Lastly, Tseng et al. were conducted in Taiwan among patients with
MetS. Overall, all included research articles discussed the cardiovascular risk factors
associated with metabolic syndrome in adults with severe mental health issues and
how they have impacted the health outcomes of the target population. Other vital
parameters assessed include the mortality rate and other metabolic abnormalities.

3.3 Quality of included articles

Applying the quality appraisal framework put forward by Caldwell et al. (2011), the nine
selected research papers were systematically assessed. All included studies were
rated using an eighteen-item assessment rubric for quantitative research. The quality
score for each study was calculated to assess the strength of the studies that were
presented.

A comprehensive assessment of the entire process and presentation of the article by

Das-Munshi et al. (2017) using the Caldwell tool showed that the article had a total
quality score of 84%. The title statement communicates the article's topic, and the
abstract lists all the critical components of the research methodology in accordance
with the evaluation criteria. Furthermore, Das-Munshi et al.'s (2017) selection of
literature for the background and literature review parts was up-to-date, trustworthy,
and made clear linkages with widely accepted beliefs regarding the subject at hand.
An important point to consider was Das-Munshi et al.'s (2017) capacity to clearly
describe the methodological approach taken for data collection and analysis. Despite
the results being presented, it was impossible to determine whether they could be
applied broadly.

Another excellent piece of evidence-based writing that made an immense contribution

to this review study is Gardner-Sood et al. (2015). The Cadwell evaluation instrument
assigned an 83% quality score for the study by Gardner-Sood et al. (2015). As shown
21
by the evaluation instrument (Appendix B), the study title is uncomplicated,
straightforward, and simple to comprehend. Additionally, the abstract sections
provided a summary of the entire research study, which made it simple for readers to
examine the article's content before reading the entire research report. The study was
quantitative, with adequate information about data collection, processing, and sample
processes. All ethical considerations about the study were adequately acknowledged
and addressed during the study. Finally, the evidence and conclusions were presented
in a clear and logical manner.

Osborn et al. (2015) conducted a prospective cohort and risk score development study
among people with a diagnosis of SMI (schizophrenia, bipolar disorder, or other non-
organic psychosis) aged 30-90 years. The article had a high-quality score of 94%,
indicating it met most of the criteria set by the Cadwell et al. (2011) appraisal
instrument. The study's title is concise and clear, and it accurately describes what it
covers. The authors are reputable researchers and are connected to a well-known
professional organisation. The study's structure was clearly defined. The population
category has been specified with valid sampling data. Osborn et al. (2015) made a
suitable and understandable presentation of the findings. Also, every discussion in the
article was interesting and pertinent.

Munshi et al. (2015) carried out a cross-sectional study in which data from selected
patients' medical records were evaluated by the primary physician using a
predesigned and pretested form. The title was straightforward and could be tied to the
most pressing issues explored in the study. The abstract, like the other included
studies, was well-written and included a summary of the research methodology and
significant conclusions. Throughout the study, the authors gave a succinct and well-
organised analysis of the pertinent data. Furthermore, the investigation's logic and aim
were adequately conveyed. Finally, the study's findings and suggestions were
accurately conveyed. A cross-sectional study conducted by Smith et al. (2020) also
met most of the standards for quantitative research that were defined by Cadwell et
al. (2011). The individuals who had MetS and bipolar disorder were evaluated for their
cardiometabolic risk profile by the authors. The data collection and analysis methods
used in the study were openly acknowledged by the authors. The information was

22
coded and organized into themes. Furthermore, all ethical concerns regarding the
research were addressed. The findings were clearly reported and explained, and
references to related literature were provided.

A quantitative research study was also carried out by Tseng et al. (2020) to establish
if the prevalence and risk factors for metabolic syndrome varied across sexes in
patients with severe mental illness. The title of the study was straightforward,
understandable, and related to its core theme. The abstract was composed effectively
and included a summary of the study procedure and significant findings, just like every
other paper that was included. The authors gave a detailed and concise outline of the
objectives and aims of the study. There were two significant limitations to this study.
Firstly, because convenience sampling was used in the study, the findings cannot be
applied to all patients with major mental illnesses. Second, determining causality
cannot be done using a cross-sectional study design. It is, therefore, necessary to
conduct more cohort studies to define the causal links.

A pilot randomised controlled trial (RCT) was carried out by Williams et al. (2019) with
40 participants, but only 33 (82.5%) of them were followed up. Leon et al. (2011)
suggested that recruitment tactics were used to produce an acceptable sample to
evaluate the viability of the study given the resources at hand. Cardiometabolic risk
factors and well-being indicators were the primary outcome assessments. The paper
received an impressive score of 94%, which indicates that it mostly met the standards
established by Cadwell et al. (2011).

When comparing patients with SMI from linked primary and secondary care
populations to the general population, John et al. (2018) conducted a retrospective
electronic cohort analysis to determine the SMRs for all-cause and cause-specific
mortality. One key aspect of this study is that it is the first to use linked data to examine
mortality for people with SMI in both primary care and secondary inpatient care
settings. Thus, the range of SMI severity among service users is covered by this
population-wide observational study. The author's study of the data was also
conducted using a strict analytical methodology. In addition, some of the drawbacks
of each level, when used separately, are balanced by the combination of the two
settings. It should be highlighted that the methodological factors and thorough
23
characterisations the researchers used to analyse the death rate in the patient
population in question are significant when influencing initiatives in policy that
strengthen services and target interventions.

Finally, Rossom et al. (2022) performed a quantitative analysis to identify unadjusted

variations in demographic traits and cardiovascular risk variables between patients
who had and did not have SMI. The title was straightforward and could be related to
the primary issues addressed in the study. The abstract was well-written and gave a
summary of the research procedure and significant findings. The researchers provided
a concise and structured examination of the essential data throughout the
investigation. In addition, the research's evidence and purpose were well
communicated. Finally, the study's conclusions and recommendations were
accurately presented.

3.4 Thematic Analysis

The main goal of this comprehensive literature review is to pinpoint and understand
the elements that elevate metabolic syndrome and early mortality risk in individuals
with severe mental disorders (SMI). As a result, the thematic analysis will be used to
examine the recurring themes or trends of high-risk factors associated with premature
deaths and metabolic syndrome among individuals with SMI. Thematic analysis is a
method of discovering and studying textual material that involves analysing,
investigating, and presenting patterns in the data through the development of a
collection of themes (Clarke and Braun, 2013). According to Vasmoradi et al. (2016),
this allows researchers to offer practical explanations for the research questions. In
accordance with the study's objectives and goals, the findings of the included research
papers were assessed and summarised using some recurrent trends that were
developed into some themes: As a result, the findings are presented using the
following theme developed by the author:

I. Prevalent risk factors for metabolic syndrome in people with SMI

II. Sociodemographic factors increase the risk of MetS in adults with SMI.
III. Mortality rates among people with SMI diagnosed with or without Metabolic
syndrome.
24
3.4.1 Theme 1: Prevalence of Metabolic Syndrome

Gardner-Sood et al. (2015) conducted a comprehensive randomised controlled study

(RCT) among participants who were suffering from severe mental health conditions.
This study aimed to determine the prevalence of cardiometabolic risk factors and the
proportion of individuals with psychosis who meet the criteria for metabolic syndrome
(MetS). Actual prevalence rates of cardiometabolic risk factors such as obesity and
type 2 diabetes were identified in the study's findings.. In a study that was quite similar
to this one, Osbourn et al. (2015) found that there were substantial connections
between documented cardiovascular risk factors and age, sex, and deprivation. These
associations all went in the direction that was anticipated for known CVD risk factors.
In comparison to the general population, Smith et al. (2020) found a significantly higher
prevalence of metabolic syndrome among individuals who had been diagnose with a
known major mental illness. According to the findings of their cross-sectional study,
the vast majority of young adults who had been diagnosed with SMI conditions such
as psychosis, schizophrenia, and bipolar disorder were at an increased risk of
acquiring MetS. According to Smith et al. (2020), this could be attributable to certain
behavioural risk factors such the body mass index (BMI), physical inactivity, and
unhealthy lifestyle behaviours. Rossom et al. (2020) came to a conclusion that was
very similar, indicating that there may be a connection between metabolic syndrome
and young individuals with SMI. According to the findings of the authors, young
persons with SMI have much higher rates of cardiovascular risk factors, which
increases the likelihood that they may acquire MetS.

3.4.2 Theme 2: Sociodemographic Factors Increasing the Risk of MetS

Munshi et al. (2015) carried out a study using a cross-sectional design in order to
establish the prevalence of metabolic syndrome among people with mental health
conditions and to search for a connection between the two types of medical problems.
Patients were split into two groups, one with the syndrome present and one without it;
then, their clinical and demographic characteristics were evaluated. The existence or
absence of the condition served as the dividing line. The authors made use of
demographic information as well as clinical data, which included age, gender, blood
pressure (BP), fasting blood glucose (FBG), total cholesterol (TC), triglycerides (TG),
25
high-density lipoprotein (HDL), and low-density lipoprotein (LDL) values. According to
the criteria established by the IDF, Munshi et al. (2015) discovered that there was an
extremely high frequency of MetS among the individuals who participated in their
research. The data also found that individuals who were prescribed antipsychotic
medication had the highest rates of MetS. Therefore, it is necessary to identify
individuals who are at high risk of developing metabolic syndrome as early as possible
so that a tailored care plan may be developed for them. It is indispensable to determine
the factors before making a management plan. In a study that was quite similar to this
one, Osbourn et al. (2015) found that there were substantial connections between
documented cardiovascular risk factors and age, sex, and deprivation. These
associations all went in the direction that was anticipated for known CVD risk factors.
Even in young individuals, there is a clear indication of a significantly elevated
cardiovascular risk associated with SMI, as described by Rossom et al. (2020). This
shows that it is crucial to address significant cardiovascular risk factors that are not
under Control in persons who have SMI at the earliest age possible. In a cross-
sectional investigation, Smith et al. (2020) presented a clinical assessment of the
cardiometabolic risk prevalence for persons with first-episode psychosis. They found
that these individuals had different cardiometabolic risk profiles. According to the data,
a high prevalence of cardiometabolic risk factors was observed due to elevated values
for body mass index (BMI), abdominal adiposity, blood pressure, and resting heart
rate.

3.4.3 Theme 3: Mortality rates among people with SMI diagnosed with or
without Metabolic syndrome.

In order to compare the mortality rates of people with SMI in connected primary and
secondary care settings to those of the general population, John et al. (2018)
undertook a retrospective electronic cohort study to determine the standardised
mortality ratios (SMRs) for all-cause and cause-specific mortality.. This was done in
order to compare the mortality rates of people with SMI to the mortality rates of the
general population. The purpose of this study was to determine the standardised
mortality ratios (SMRs) for all-cause mortality as well as cause-specific mortality in
persons with SMI. They discovered that patients with SMI have a higher risk of dying

26
from reasons that are ill-defined and unknown, from suicide as well as other less
common and frequently under-reported causes of death. Das-Munshi et al. (2017)
conducted a study of persons with a valid diagnosis of severe mental illness that was
in the form of a longitudinal cohort study. The investigation revealed that those with
serious mental illnesses have a higher mortality rate compared to the general
population, and this is true regardless of ethnicity. In contrast to the findings of the
research carried out by John et al. (2018), the findings of the cohort study carried out
by Dan-Munshi et al. (2017) revealed that, among people who have a severe mental
illness, certain ethnic minorities have a lower mortality rate than the white British
group. This lends credence to the idea that ethnicity is a candidate for the role of a
potential mortality predictor among patients with SMI and MetS. When compared to
the overall population, this points to a higher risk being posed by young adults.

27
 CHAPTER FOUR
DISCUSSION
4.1 Discussions

In people who have severe mental illnesses (SMI), the focus of this study is on the
factors that put them at risk for metabolic syndrome and early mortality. The incidence
of metabolic syndrome among patients who have been diagnosed with significant
mental health issues has been a recurrent theme throughout this review (Gardner-
Sood et al., 2015; Osbourn et al., 2015). According to the findings of Gardner-Sood et
al. (2015), multiple cohorts of persons with established psychosis demonstrated a
considerable prevalence of both individual cardiometabolic risk factors and the Mets.
This finding is in line with the findings of studies conducted by Mitchell et al. (2013)
and Nilsson et al. (2019), which discovered a higher prevalence compared to that of
the general population. It is common knowledge that individuals who are diagnosed
with severe mental illness (SMI) have an increased chance of developing metabolic
syndrome and, as a direct consequence of this, a greater likelihood of passing away
at an earlier age. Osburn et al. (2015) discovered significant correlations between age,
gender, and deprivation and recorded cardiovascular risk factors. These significant
relationships all followed the trend that was predicted for known cardiovascular risk
factors in adults with SMI.

In addition, Tseng et al. (2020) confirmed that patients with severe mental illness are
more likely than the general population to have metabolic syndrome and its related
problems. This was found to be the case when comparing the two populations. Tseng
et al. (2020) indicate, based on their findings, that mental health practitioners should
take into consideration the gender- and age-based prevalence trend in severe mental
illness patients when establishing treatment strategies for the study population to lower
the occurrence of metabolic syndrome. This is to help reduce the number of people
who suffer from the condition. When it comes to addressing the issue of MetS in
patients who have SMI, this indicates that additional variables, like gender and age,
need to be investigated as part of the solution. This may play an important part in
resolving difficulties about untimely deaths within this population group.

28
Researchers Munshi et al. (2015) did a study to determine the incidence of metabolic
syndrome among people with mental illness and to evaluate any possible connections
between the two medical conditions. Patients were divided into two groups, one with
the condition present and one without it so that clinical and demographic information
could be compared between the two sets of patients. According to the findings of the
study, SMI is relatively standard among members of this demographic. Further,
Munshi et al. (2015) asserted that the high prevalence of MetS among people who
have SMI has contributed to an increase in the probability of an untimely demise in
this population group. According to Rossom et al. (2022), who stated that some of the
primary risk factors were specific behavioural and lifestyle factors, such as alcohol
intake and smoking, and a higher BMI was also highlighted as a risk factor.

Studies (Hayes et al., 2017; Lambert et al., 2022; Public Health England, 2022) have
revealed that patients who exhibit specific metabolic syndrome have a higher risk of
dying prematurely than the general population. According to John and colleagues
(2018) findings, substance misuse and suicidal thoughts are two main risk variables
that are related to an elevated risk of premature death in patients with SMI who also
have MetS. According to Gardner-Sood et al. (2015), some high-risk factors, including
the use of antipsychotics, obesity, hypertension, and dyslipidemia mau, have raised
the risk of premature deaths in patients with SMI. A clinical summary of the prevalence
of cardiometabolic risk was provided by Smith et al. (2020) through the use of a cross-
sectional survey for individuals who had psychosis for the first time. The findings
indicated a statistically significant increase in the prevalence of cardiometabolic risk
factors, as seen by higher values for body mass index (BMI), abdominal obesity, blood
pressure, and resting heart rate. According to John et al. (2018), the following are the
primary risk factors that were found as predictors for early death among those who
suffer from severe mental health problems. It has been discovered that the prevalence
of metabolic syndromes is highest among patients who have significant mental health
illnesses (Boreu et al., 2013; Baxter et al., 2016). These characteristics point to the
presence of metabolic syndromes. This is very important because a number of studies
have shown that people with SMI are more likely to lead unhealthy lifestyles, take
antipsychotic drugs, and receive less conventional medical care than the general
population (Baxter et al., 2016; Fern, 2018; Vancampfort et al., 2015). All of these
29
factors increase the risk of developing cardiovascular disease in people with SMI
(Baxter et al., 2016; Fern, 2018; Vancampfort et al. These factors, in the end,
contribute to an increased risk of death during premature birth when compared to the
whole population.

According to some findings, people who have a severe mental illness (SMI) are at an
increased risk of developing metabolic syndrome and have a greater likelihood of
passing away at a younger age (Boreu et al., 2013; Baxter et al., 2016; Holt et al.,
2010). This has led to the opinion that a few multifactorial factors can influence a
person's likelihood of getting metabolic syndrome and/or living a shorter lifetime. This
belief has been established as a result of this. In order to improve and optimise care
delivery in the real world, it is vital to do an in-depth review of the research that was
conducted on metabolic syndrome and early deaths in patients who have a severe
mental illness. This review substantiated the premise that there is support for the
hypothesis that people with SMI have an increased risk of dying from early causes.
There is a correlation between this risk and the cardiovascular risk factors that are
associated with metabolic syndrome in those who have SMI. Some of the contributing
variables are being overweight, having diabetes, having high blood sugar levels, and
having hypertension.

4.2 Strength and Limitations

According to Aveyard (2019), the benefits and drawbacks of each research study are
highly contingent on the methodology that the researchers choose to use. According
to Paré and Kitsiou (2017), literature reviews are dependent on the findings of the
primary research that is incorporated into the analysis. As a consequence of this, the
correctness and dependability of such analyses are contingent upon the original
research that was used. Screening methods and quality rating tools are applied,
according to Mohajan et al. (2017), in order to evaluate the significance and relevance
of the leading research that is included in the study. This ought to assist in minimising
the influence of confounding variables, bias, and individual errors that were made in
the primary research, reinforcing the general outcomes and the conclusions of this
study (Kahlert et al., 2017). As a result, the research methods utilised throughout the

30
process of data collection and analysis lend some credibility to the previously
mentioned review study.

This review study has a number of advantages, one of which is that it provides access
to current and relevant research publications that are in line with the goals and
intentions of the study. (Dale et al., 2019) The study that was included was obtained
after a methodical and extensive search of the available literature resources on
metabolic syndrome and mental health problems among young individuals. Bramer et
al. (2017) stressed the relevance of using databases that are reliable and valid when
doing literature searches, as well as the importance of combining different database
sources that are complementary to one another. This research project used a total of
three different online health databases to conduct its literature review. Articles from
relevant studies that may be used for the desired study context that was being
researched were made available by the databases. In addition to this, there was a
crystal-clear depiction of the search technique that can be repeated, and similar
findings show that it is reliable and replicability (Health et al., 2022).

The author would like to point out some of the limitations of this study, just like they do
with many other review studies. Because of the modifications that were made to the
study site parameter in the eligibility criteria, it was not possible to generalise the
findings of the research to the population of the United Kingdom. This presents a
severe problem. The evaluation took into account studies from other countries; hence,
the conclusions should not be extended to apply solely to young adults in the UK. Even
if the primary goal of establishing this pattern in a population from the UK still needs
to be accomplished, readers are able to compare the data on the subject between two
settings that are very comparable. Due to the fact that this was an independent
academic endeavour, there was no possibility of a second reviewer taking part in the
research study to assist in lowering the potential for bias. When doing a review study,
it is always necessary to have an evaluation and assessment carried out by a number
of different authors in order to improve the rigour and quality of the study (Nowell et
al., 2017). The supervisor of the project did, however, offer guidance on how to
enhance the calibre of the study that was being conducted. The fact that the data that
were collected from each of the primary research investigations that were included in

31
the analysis were not statistically similar further raises doubts regarding whether or
not the conclusions of the present review should be generalised. In conclusion, the
conclusions should be viewed with some degree of scepticism because the author
may need to pay more attention to more than a few particular findings from the original
research that were taken into account.

32
 CHAPTER FIVE
CONCLUSION
5.1 Conclusions

Metabolic syndrome, often known as MetS, is a clustering of cardiovascular risk

factors that includes dyslipidemia, overweight, high blood pressure, and high blood
sugar levels. These risk factors are strongly connected to an increased risk of mental
health issues. Researchers have found a correlation between major mental illness and
an increased likelihood of having metabolic syndrome (MetS). Penninx and Lange
(2018). The increased risk is apparent for a few mental disorders, the most notable of
which are Schizophrenia, Bipolar disorder, Depression, Major Depressive disorder
(MDD), Anxiety-related disorders, Attention-Deficit or Hyperactivity Disorder (ADHD),
and Post-traumatic stress disorder (PTSD). As a consequence of this, the review study
will endeavour to identify and analyse the factors that are related to an elevated risk
of premature mortality and metabolic syndrome in individuals who have a significant
mental illness. It is common knowledge that people who have a severe mental illness
(SMI) have an increased risk of developing metabolic syndrome and passing away at
an earlier age (Baxter et al., 2016; Fern, 2018; Vancampfort et al., 2015). The objective
of the ELR was to generate essential knowledge from the data by identifying the
variables that are related to elevated risks of metabolic syndrome and premature death
in persons who have a severe mental illness. The complete assessment of nine
publications that had been peer-reviewed and met the criteria for inclusion yielded
findings that helped to understand the factors that are related to an increased risk of
metabolic syndrome and premature death in adults who have a severe mental illness.
The results of this study shed light on the significant frequency of cardiometabolic risk
factors that can be modified in patients who suffer from severe mental problems.

The findings of the review indicate that people who suffer from severe mental illnesses
have an increased risk of passing away at a younger age due to the impact of specific
conditions associated with metabolic syndrome as well as other factors, such as
different socio-environmental factors, variations in underlying physical well- being,
and variations in the prescription of psychotropic drugs, amongst others (Gardner-

33
Sood et al., 2015; Vaismoradi et al., 2016). There is a possibility that these factors
play a significant role in lowering the risk of mortality in people who have severe mental
illness. Adults who suffer from severe mental health conditions are at a greater risk of
developing metabolic syndrome, which is correlated with an increased risk of dying at
an earlier age. According to the findings of the analysis, some cardiometabolic risk
factors, such as being overweight and having type 2 diabetes, were associated with
an increased risk of dying prematurely in persons who suffered from significant mental
health conditions and metabolic syndrome. Another critical element was the increased
incidence of metabolic syndrome in individuals who were taking particular
antipsychotic medications. This finding hints that the dosage and type of antipsychotic
medication may also play a role in the incidence of premature death and MetS in
patients with SMI. The review also discovered that people with SMI have a higher
chance of dying from ill-defined and unexplained reasons, as well as from suicide and
other less common and sometimes under-reported causes that are frequently related
to certain cardiovascular risk factors.

5.2 Recommendations/Implications for Practice

Because metabolic syndrome (MetS) has adverse effects on physiological as well as

mental outcomes for people with serious mental illnesses, integrated pharmaceutical
therapies treating metabolic imbalances and mental illnesses in combination with
behavioural approaches may help reduce the illness burden (Smith et al., 2020).
According to Penninx and Lange (2018), taking this action can help mitigate the
negative consequences of the cardiovascular risk factors that contribute to an elevated
risk of mortality and metabolic syndrome in individuals who suffer from significant
mental health conditions. It is recommended to treat mental disorders and metabolic
syndrome jointly in order to improve the outcomes of treatment for both conditions and
lower the chance of dying too soon.

34
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41
 Appendices

Appendix A: PRISMA Flow Chart

IDENTIFICATION

Articles obtained through

Extra articles were
searching databases.
obtained through other
(n=181)
sources.
(n=2)

Articles after the removal of Articles excluded.

duplicates (n=27)
(n=67)
SCREENING

Articles screened. Articles excluded.

(n=40) (n=16)

Articles excluded (n=15)

ELIGIBILITY

Articles assessed for

eligibility. Not enough data (n=5)
(n=24) Wrong study design (n=5)
Wrong outcome (n=5)
INCLUDED

Articles included for

review.
(n=9)

42
Appendix B: Cadwell et al. (2011) Appraisal Tool
S/N Quantitative Studies Das- Gardner- John et Munshi Osborn Rossom Smith Tseng Williams
Munshi et Sood et al. et al. et al. et al. et al. et al. et al.
al. (2017) al. (2018) (2015) (2015) (2022) (2020) (2020) (2019)
(2015)
1. Does the title reflect the content? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

2. Are the authors credible? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

3. Does the abstract summarize the key ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

components?
4. Is the rationale for undertaking the research ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
clearly outlined?
5. Is the literature review comprehensive and up ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
to date?
6. Is the aim of the research clearly stated? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

7. Are all ethical issues identified and clearly ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

addressed?
8. Is the methodology identified and justified? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

9. Is the study design clearly identified, and is ✖ ✔ ✔ ✔ ✖ ✖ ✔ ✔ ✔

the rationale for the choice of design evident?
10. Is there an experimental hypothesis clearly ✖ ✔ ✔ ✔ ✖ ✖ ✔ ✔ ✔
stated? Are the key variables clearly defined?
11. Is the population identified? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

12. Is the sample adequately described and ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

reflective of the population?
13. Is the method of data collection valid and ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
reliable?
14. Is the method of data analysis valid and ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
reliable?
15. Are the results presented in a way that is ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
appropriate and clear?

43
16. Is the discussion comprehensive? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

17. Are the results generalisable? ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖

18. Is the conclusion comprehensive? ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Total quality score in percentage 83 94 94 94 83 83 94 94 94

44
 Appendix C: Summary of included studies
S/N Author (Year) Aim of study Journal Study design and Measures Strength/Limitations Main findings
sample size

1. Das-Munshi et Estimate the excess Lancet Psychiatry Quantitative All-cause and Strength: People with severe
al. (2017) fatalities of people with Study cause-specific mental illness have
major mental illness in ▪ Good sample size. excess mortality relative
mortality by
five ethnic groups (white ▪ Representative to the general
British, black Caribbean, ethnicity, sample. population, irrespective
“Ethnicity and black African, South A longitudinal normalised by ▪ Ethical issues of ethnicity.
excess mortality Asian, and Irish) and cohort study looks age and sex for discussed.
in severe mental examine ethnicity and at the lives of this group
illness: a cohort death risk. people who have
study”. been diagnosed Among those with
with a severe severe mental illness,
mental illness. some ethnic minorities
have lower mortality
Location: than the white British
group.
United Kingdom
2. Gardner-Sood et To determine the Psychological Medicine Quantitative Prevalence rates of Strength: High rates of
al. (2015) prevalence of Study cardiometabolic risk cardiometabolic risk
cardiometabolic risk factors. ▪ Good sample size. factors were found.
factors and establish the ▪ Representative
proportion of people with sample.
“Cardiovascular psychosis meeting the ▪ Ethical issues
risk factors and criteria for metabolic Rates of the MetS, discussed. There were a high
metabolic syndrome (MetS). The A large randomized using the number of participants
syndrome in study also aimed to controlled trial International who were obese, having
people with identify the critical Diabetes Federation
established lifestyle behaviors (IDF) and National
45
 psychotic associated with Cholesterol high BMI and waist
illnesses: increased risk of the Education Program circumference.
baseline data MetS and to investigate Third Adult Treatment
from the IMPaCT whether the MetS is Panel criteria
randomised associated with illness
controlled trial”. severity and degree of Type 2 diabetes was
functional impairment. also prevalent.

Location:

United Kingdom
3. John et al. To estimate SMRs for Schizophrenia Quantitative To figure out SMI Strength: They found that people
(2018) all-cause and cause- Research Study SMRs from linked with SMI are more likely
specific mortality in SMI populations of ▪ Good sample size. to die by ill-defined and
patients from connected primary care, ▪ Representative unknown causes,
primary and secondary secondary care, and sample. suicide, and other less
“Premature care populations A retrospective the general public. ▪ Ethical issues common and often
mortality among compared to the general electronic cohort discussed. under-reported causes.
people with population.. study.
severe mental
illness — New
evidence from
linked primary
care data”.

Location:

United Kingdom

46
4. Munshi et al. To determine the Journal of Pakistani Quantitative Demographic and ▪ Good sample size. There was a high MetS
(2015) frequency of Metabolic Medical Association Study clinical data, ▪ Ethical issues prevalence in the study
Syndrome among including age, discussed. population, with 48%
psychiatric patients and gender, blood meeting the criteria
to look for the correlation pressure (BP), FBG, according to the IDF
“Frequency of between the two medical total cholesterol (TC), definition.
metabolic conditions. triglycerides (TG),
syndrome in Cross-sectional high-density
psychiatric study lipoprotein (HDL) and
patients, is this low-density
the time to lipoprotein (LDL)
develop a levels.
standardised
protocol to
reduce the
morbidity from an
acute care
psychiatry unit”.

Location:

Canada
5. Osborn et al. To find out how often JAMA Psychiatry Quantitative Ten-year risk of a first Strength: Associations between
(2015) Metabolic Syndrome Study cardiovascular event. age, sex, deprivation
happens in mental ▪ Large numbers of and established
patients and to see if people with SMI cardiovascular risk
there is a link between are representative factors were all in the
“Cardiovascular the two health Prospective cohort Predictors included of the UK SMI expected direction for
risk prediction problems.variables. and risk score age, gender, height, population. known CVD risk factors.
models for development study. weight, systolic blood
47
 people with pressure, diabetes, ▪ Adequate follow-up
severe mental smoking, body mass period.
illness: results index (BMI), lipid
from the profile, social Weakness:
prediction and deprivation, SMI
management of diagnosis, ▪ The data collection
cardiovascular prescriptions of process might be
risk in people antidepressants, affected.
with severe antipsychotics, and
mental illnesses reports of heavy
(PRIMROSE) alcohol use.
research
program”.

Location:

United Kingdom
6. Rossom et al. To compare the Journal of the American Quantitative Those without Strength: The significantly
(2022) expected 10-year and Heart Association Study cardiovascular increased cardiovascular
30-year cardiovascular disease between the ▪ The UK SMI is risk associated with SMI
risk in primary care ages of 40 and 75 shown by the large is evident even in young
patients with severe who had scores for number of people adults. This suggests the
“Cardiovascular mental illness and those chronic with SMI. importance of
Risk for Patients who don't have it. cardiovascular ▪ Ethics were taken addressing uncontrolled
with and Without Descriptive disease were used to into account. major cardiovascular risk
Schizophrenia, analysis was figure out the 10-year ▪ Findings are factors in those with SMI
Schizoaffective conducted to cardiovascular risk. generalisable. at as early an age as
Disorder, or determine possible.
bipolar disorder”. unadjusted
differences in
48
 demographic 30-year
characteristics and cardiovascular risk
Location: cardiovascular risk was estimated using
factors between Framingham risk
United States patients with and scores for patients
without diagnosed aged 18 to 59 years
SMI and among without
patients with cardiovascular
different SMI disease
diagnoses.

7. Smith et al. To present a clinical Frontiers in Quantitative Cardiometabolic risk Strength: High prevalence of
(2020) overview of the Endocrinology Study profile. cardiometabolic risk
cardiometabolic risk ▪ Ethical approval factors due to elevated
prevalence for was obtained. values for BMI,
individuals with FEP with ▪ Good sample size. abdominal adiposity,
“Cardiometabolic a short DUP on Cross-sectional These include blood pressure, resting
Risk in First presentation to a UK Study anthropometric, heart rate,
Episode Early Intervention in health risk behaviors hypercholesterolemia,
Psychosis Psychosis (EIP) service and clinical suboptimal HDL-C
Patients”. measurements, levels, and
including resting hypertriglyceridemia.
heart rate, blood
pressure, blood
Location: lipids, glycated
haemoglobin, and
United Kingdom prolactin

49
8. Tseng et al. To determine whether International Journal of Quantitative Demographic Strength: The prevalence of MetS
(2020) metabolic syndrome Mental Health Nursing Study characteristics, was relatively high
prevalence and risk lifestyle behavior ▪ Good sample size. (40.8%), with the
factors differ between factors, biochemistry, ▪ Representative prevalence higher in
male and female and anthropometry. sample. women.
“Gender patients with serious ▪ Ethical issues
differences in mental illness. discussed. Age was another
metabolic Cross-sectional significant risk factor,
syndrome risk study. Metabolic syndrome with MetS higher among
factors among (MetS) was defined people with SMI who
patients with based on National were below 40 years
serious mental Cholesterol compared to the general
illness”. Education Program, population.
Adult Treatment
Panel III (NCEP-ATP BMI, lack of physical
III) guidelines. activity and being
Location: obese/overweight were
associated with SMI.
Taiwan

9. Williams et al. To test the feasibility and BMC Psychiatry Quantitative Cardiometabolic risk Strength: The intervention was
(2019) acceptability of 'Walk Study factors and well- feasible and acceptable
this Way' to reduce the being measures. ▪ Ethical issues to participants.
risk of CVD and SB, addressed. Preliminary results were
which are independent encouraging, with
“‘Walk this way’: risk factors for mortality A pilot Randomized Weaknesses: improvement seen in
results from a among people with SMI Controlled Trial both SB and PA.
pilot randomised (RCT) ▪ The sample is not
controlled trial of Sedentary Behavior significant.
a health coaching (SB)
intervention to
50
reduce sedentary ▪ Selection bias This can contribute to
behaviour and reducing the risk of
increase physical 40 people were premature death.
activity in people recruited, but only
with serious 33 (82.5%) were
mental illness”. followed up

Location:

United Kingdom

51