Lifestyle and physical health in schizophrenia by MikeJenny


									Lifestyle and physical health in schizophrenia
Moira Connolly and Ciara Kelly

Adv. Psychiatr. Treat. 2005 11: 125-132
Access the most recent version at doi:10.1192/apt.11.2.125

        Reprints/      To obtain reprints or permission to reproduce material from this paper, please write
     permissions       to

You can respond
 to this article at
   Email alerting      Receive free email alerts when new articles cite this article - sign up in the box at the
         service       top right corner of the article or click here

     Downloaded on June 29, 2011
           from        Published by The Royal College of Psychiatrists

To subscribe to Advances in Psychiatric Treatment go to:
                                                                              Lifestyle and physical (2005), vol. 11, 125–132
                                                                  Advances in Psychiatric Treatment health in schizophrenia

Lifestyle and physical health
in schizophrenia
Moira Connolly & Ciara Kelly

  Abstract People with schizophrenia die prematurely. Their illness, its treatment and their lifestyle all contribute
                 to the excess morbidity and mortality. Lifestyle ‘choices’ (e.g. poor diet, low rates of physical activity
                 and increased likelihood to smoke cigarettes) predispose them to poor physical health and comorbid
                 medical diseases. In addition, weight gain and obesity are a consequence of most antipsychotics,
                 particularly the atypicals. Excessive body weight increases the risk of morbidity and mortality, and is
                 the biggest risk factor for type II diabetes in schizophrenia. Much of the excess mortality of schizo-
                 phrenia is preventable through lifestyle and risk factor modification and the treatment of common
                 diseases, but the potential for improving outcomes in this area is only starting to be addressed.

This article is the second of two in this issue in a series introduced   quality of life. The general lifestyle and physical
by Robin McCreadie’s editorial ‘Schizophrenia revisited’
(McCreadie, 2004). In the first, Kerwin & Bolonna (2005) discuss         health of patients with schizophrenia are relatively
treatment-resistant schizophrenia. Previous contributions have           rarely studied.
considered environmental influences (Leask, 2004), implementation          In this article, we bring together these areas of
of the NICE schizophrenia guidelines (Rowlands, 2004), cognitive
deficits in first-episode schizophrenia (Gopal & Variend, 2005)          research and practice to inform the debate on how
and early intervention in psychosis (Singh & Fisher, 2005).              to improve the physical health of patients with
                                                                         schizophrenia and, ultimately, overall outcomes for
                                                                         the illness.
People with schizophrenia have a higher risk of
medical illness than does the general population.
They also have an increased (by two- to fourfold)                        Risk factors
relative risk of premature death, dying at least 10
years earlier than age-matched contemporaries                            Morbidity can be estimated individually using
(Brown, 1997; Joukamaa et al, 2001). Brown’s study                       predictive risk factors and markers, some clearly
of mortality in schizophrenia found that 12% of                          modifiable and others not (Box 1). Modifiable risk
reported deaths were by suicide, which accounted                         factors are prevalent in people with schizophrenia.
for 28% of the excess. A further two-thirds of this                      They are a consequence of the illness itself, and of
excess was attributed to ‘natural causes’ such as                        associated behaviours, lifestyle and treatment. It is
cardiovascular disease, respiratory disease and                          clearly important that services available to people
diabetes.                                                                with schizophrenia appreciate the inflated risk and
   Undoubtedly, much of the excess morbidity and                         how it contributes to morbidity and premature
mortality of schizophrenia is preventable through                        mortality in these individuals.
lifestyle modification and the recognition and treat-
ment of common diseases. Although there is a clear
evidence base acknowledging the poor physical                            Lifestyle
health of people with mental illness, the potential
for improving outcomes in this area has been largely                     Our lifestyle choices are influenced by a variety of
neglected in both research and clinical practice.                        factors such as genes, environment and socio-
   With changing clinical practice, outcome studies                      demographic status. In schizophrenia, the illness
have tended to concentrate on psychiatric outcomes                       itself also plays a part. A drift down the social scale
– symptomatology, service use, level of function and                     associated with unemployment and poorer financial

Moira Connolly is a consultant general psychiatrist at Gartnavel Royal Hospital (Great Western Road, Glasgow G12 0XH, UK.
E-mail: with interests in psychiatric rehabilitation and cognitive–behavioural therapy.
She is an honorary senior lecturer at the Department of Psychological Medicine, University of Glasgow, where her research
interests include the physical health of people with schizophrenia. Ciara Kelly is a consultant psychiatrist working in rehabilitation
at Leverndale Hospital, Glasgow, with academic time spent in the Department of Psychological Medicine, Glasgow University.
Her current research interests are the lifestyle, physical health and outcome of people with schizophrenia.

Advances in Psychiatric Treatment (2005), vol. 11. http:/                                                                        125
Connolly & Kelly

                                                             and vegetable consumption averaged 16 portions
  Box 1 A brief explanation of risk                          per week (less than half the recommended intake),
                                                             and very few patients made acceptable dietary
  •   A risk factor is a manifestation or a laboratory
                                                             choices across a range of foodstuffs. Vitamin C levels
      measurement that expresses the likelihood
                                                             correlated with fruit and vegetable intake, carotenoid
      that an individual or a group will develop a
                                                             levels were indicative of a diet containing little in
      disease over a defined period of time
                                                             the way of fruit and vegetables, and folate deficiency
  •   A risk factor may play a causal role in the            was detected in 2% of patients.
      pathogenesis of a disease or it may be an                It is clear that the diet of people with schizo-
      associated marker. For example, low-density            phrenia in Scotland is at least as poor as that of the
      lipid (LDL) cholesterol is a risk factor in            general population in social class V (the lowest
      coronary heart disease proven to be modifi-            social class). In a nation whose dietary habits are
      able in intervention trials, whereas C-reactive        among the poorest in Europe, this is concerning.
      protein is a risk marker – it is associated with         Minimal consideration has been given to explana-
      coronary heart disease but is not necessarily          tory factors for the poor diet of this patient group,
      causal                                                 and dietary interventions have tended to centre on
  •   Specific diseases can have both modifiable             the impact of vitamins or omega-3 fatty acid
      and non-modifiable risk factors. For example,          supplementation on mental health, with varying
      modifiable risk factors for coronary heart             outcomes (Joy et al, 2003).
      disease include obesity, dyslipidaemia,
      diabetes, hypertension, smoking and psycho-            Physical activity
      logical state
                                                             Brown et al (1999) and McCreadie (2003) found that
                                                             people with schizophrenia tended to take only small
standing once the illness is established is not              amounts of exercise. The reason for this has not been
unusual. It is also hypothesised that an ‘urban risk         demonstrated, but factors such as features of the
factor’ operates in the aetiology of schizophrenia,          illness, sedative medication and lack of opportunity
increasing its incidence (Jablensky, 1999).                  and general motivation may be relevant.
  Two fairly recent studies (Brown et al, 1999;                 The relative risk of atherosclerosis in physically
McCreadie, 2003) have compared the lifestyle of              inactive individuals is higher than in those who are
people with schizophrenia living in the community            more active. The specific mechanism by which
with that of low social class cohorts from existing          physical activity reduces mortality from cardio-
general population studies of lifestyle habits. In both      vascular disease is unknown, but exercise has been
studies, people with schizophrenia made signifi-             shown to improve lipid profiles, glucose tolerance,
cantly poorer dietary choices, took less exercise and        obesity and hypertension.
smoked more heavily than the comparator groups
in the general population. McCreadie also found
that women with schizophrenia were significantly             Smoking
more likely to be overweight or obese than women
in the general population (a result not found by             It has been suggested that smoking represents the
Brown et al).                                                most extensively documented cause of disease ever
  Given that poor diet, smoking and excess weight            investigated in the history of biochemical research.
are potentially modifiable factors associated with           Smoking remains the single greatest preventable
increased physical morbidity and mortality, we will          cause of death in our society.
consider further the extent of these problems in                A review of smoking and schizophrenia published
patients with schizophrenia.                                 in a previous issue of APT (Kelly & McCreadie, 2000)
                                                             noted the following findings.
                                                                The prevalence of smoking in schizophrenia
Diet                                                         greatly exceeds that in the general population (75–
                                                             92% v. 30–40%). Furthermore, heavy cigarette
A small case–control study in a Scottish population          smoking is intimately associated with schizophrenia
demonstrated that people with schizophrenia made             and it may have implications for the underlying
poor dietary choices, characterised by high fat and          neurobiology of the disease. Patients who smoke
low fibre intake (McCreadie et al, 1998). The subse-         report increased cigarette consumption, are more
quent larger study (McCreadie, 2003) examined in             addicted to nicotine and have higher nicotine levels
detail the dietary intake of 102 people with                 in the bloodstream. Smoking may be a marker for a
schizophrenia in Dumfries and Glasgow. Their fruit           more severe illness. Cigarette smoking induces

126                                     Advances in Psychiatric Treatment (2005), vol. 11.
                                                                 Lifestyle and physical health in schizophrenia

hepatic microsomal enzymes, which increase the
metabolism of psychotropic medication; therefore             Box 3 Effects of weight gain in people with
smokers usually require greater levels of anti-              schizophrenia (Tardieu et al, 2003)
psychotic medication than non-smokers to achieve             •   Health risks
similar blood levels.                                            • hypertension
   Most heavy smokers find it very difficult to give             • atherosclerosis
up, and success rates are even lower in people with              • type II diabetes mellitus
psychiatric illness. Attempts to get patients with               • cardiovascular disease and stroke
schizophrenia to stop smoking have met with                  •   Stigmatisation
variable success. It is widely believed (by mental           •   Non-adherence to treatment
health professionals, families, carers and patients          •   Further impairment of quality of life
themselves) that it is one of the patients’ few              •   Social withdrawal
pleasures, that it is ‘hopeless’ to try to quit and that
to do so will aggravate their mental state. This view
is discriminatory. In a survey of cigarette-smoking        associated with dyslipidaemia, hypertension and
patients, one-third reported that they wanted to quit      glucose intolerance. Risk of comorbid diseases has
for health reasons. Clearly, smokers with schizo-          been shown to rise as BMI increases above 25 kg/m2
phrenia have a severe nicotine addiction, and              and waist circumference increases above 102 cm for
pharmacological and psychological support with             men or 89 cm for women (Aronne, 2001). Increased
cessation needs to address their particular needs.         rates of diabetes have also been shown to be related
There is some evidence that clozapine, and possibly        to body fat distribution (Ryan & Thakore, 2002).
other atypicals, reduce cigarette consumption.                In psychiatric practice, weight gain is a long-
                                                           recognised and commonly encountered problem. In a
                                                           review of the literature, Allison & Casey (2001) report
Obesity                                                    on a study that used the 1989 US National Health
                                                           Interview Survey data comparing weights and
Although often not viewed as a health problem, being       heights of people with and without schizophrenia. In
overweight or obese (Box 2) has reached epidemic           general, the results showed that those with schizo-
proportions worldwide. Excessive body weight sub-          phrenia were more obese than those without, and that
stantially increases the risk of morbidity from a          the difference was significant for women. Another
number of conditions, including hypertension, dys-         study reviewed by Allison & Casey, of 151 people with
lipidaemia, type II diabetes mellitus, coronary heart      schizophrenia, reported 51% of males and 59% of
disease, stroke, gallbladder disease, osteoarthritis,      females to be clinically obese, compared with 33% of
sleep apnoea, respiratory problems and endometrial,        people with other psychiatric disorders.
breast, prostate and colon cancers. Higher body
weight is associated with increased mortality as
well as with social stigmatisation (Meltzer &              The role of antipsychotics
Fleischhacker, 2001). Excess abdominal fat is
                                                           Antipsychotic-related weight gain was first reported
                                                           in association with chlorpromazine in the late 1950s,
                                                           but it has remained overshadowed by other side-
  Box 2 Body weight and obesity
                                                           effects such as extrapyramidal symptoms and
  The body mass index (BMI)                                tardive dyskinesia. Among the conventional anti-
  Determined as weight divided by the square of            psychotics, weight-gain liability appears to be
  height (kg/m2), BMI is one measure of body               greatest with low-potency drugs. Meta-analyses,
  weight. ‘Overweight’ is defined as BMI ≥ 25 kg/          clinical trials and clinical experience suggest that
  m2 and ‘obese’ as BMI ≥ 30 kg/m2                         the atypical antipsychotics can also cause marked
                                                           weight gain during treatment. Box 3 outlines some
  Waist circumference
                                                           of the consequences of this problem.
  This is another useful measure because it is an
                                                              Not all antipsychotics have the same propensity
  indicator of the amount of abdominal fat. It is
                                                           for causing weight gain (Box 4), but those associated
  easy and cheap and is highly correlated with
                                                           with the greatest gain, clozapine and olanzapine,
  specific measures of abdominal fat including
                                                           can add up to 4.5 kg after 10 weeks of treatment at
  more complex imaging
                                                           standard dose. Also, patients appear to differ in
  Waist-to-hip ratio                                       their weight-gain response to specific drugs. Little
  Expression of abdominal fat in this form is no           is known about individual predictors, but most
  longer considered necessary (Ryan et al, 2003)           weight gain appears to occur during the first 2 years
                                                           of treatment, and it accompanies an increase in

Advances in Psychiatric Treatment (2005), vol. 11. http:/                                                     127
Connolly & Kelly

  Box 4 Effect on weight of different anti-
  psychotics (after Zimmerman et al, 2003)                   Managing obesity in people with schizophrenia can
                                                             be daunting. Compared with non-obese patients,
  Marked weight gain
                                                             obese patients are 13 times more likely to request
  • Clozapine
                                                             discontinuation of their current antipsychotic
  • Olanzapine
                                                             medication because of concerns about weight gain
  • Zotepine
                                                             and 3 times more likely to fail to adhere to treatment
  • Quetiapine
                                                             regimens (Kurzthaler & Fleischhacker, 2001).
  • Chlorpromazine
                                                                Weight-loss interventions for people with schizo-
  • Thioridazine
                                                             phrenia should start with regular and frequent
  • Perphenazine
                                                             weight monitoring and should advise on exercise
  • Trifluoperazine
                                                             and lifestyle. Switching of antipsychotic medication
  Moderate weight gain                                       to one with less propensity for weight gain should
  • Risperidone                                              also be considered.
  • Clopenthixol                                                In general, pharmacotherapy should be reserved
  • Sulpiride                                                for obese patients who fail to lose weight after
  Slight weight gain                                         several months of behavioural interventions, and
  • Amisulpride                                              particularly for those with comorbid disorders such
  • Haloperidol                                              as diabetes. One of the new anti-obesity drugs
  • Fluphenazine                                             orlistat, a lipase inhibitor, may be the best choice for
  • Flupentixol                                              the treatment of obesity in people with chronic
                                                             mental illness. Long-term general population studies
  No weight change                                           show sustained weight loss of 9.7% at 2 years with
  • Ziprasidone
                                                             a dose of 120 mg thrice daily with meals. Improve-
  Weight loss                                                ments in fasting lipid profiles and glucose tolerance
  • Molindone                                                were noted. There have been case reports of its safe
  • Pimozide                                                 and effective use in psychiatric patients, with no
                                                             effects on the bioavailablity of psychotropic
  No data available
                                                             medication. However, to date there have been no
  • Aripiprazole
                                                             randomised controlled trials of its use in such
                                                             populations (Hilger et al, 2002).
appetite, especially for sweet and fatty foods, with
no clear impact on basal metabolic rate.                     Lipids
   Fontaine et al (2001) estimated the consequences
of antipsychotic-induced weight gain (0 to 12.75 kg)         Elevated blood lipids, particularly triglycerides, are
on selected mortality rates and the incidence of             associated with some typical antipsychotic agents.
diabetes and hypertension in US adults. For people           Shortly after their introduction, phenothiazines were
who moved into the overweight and obese BMI                  found to elevate serum triglyceride and total
categories, the gain was expected to result in 258           cholesterol levels. This compared with a minimal or
deaths per 100 000 people over 10 years. A gain of           slightly favourable effect seen with butyrophenones.
2.5 kg was expected to result in 350 cases of impaired          Much has been written on the effects of specific
glucose tolerance and 1850 cases of hypertension             atypical drugs on lipid profiles. Both clozapine and
per 100 000 people.                                          olanzapine have been shown to cause significant
   These figures are of profound clinical and public         hypertriglyceridemia compared with typicals. Some
health significance. Of particular interest in relation      studies have reported a significant association
to current health policy are Fontaine et al’s conclu-        between weight gain and triglyceride change for
sions regarding suicide rates. The government of             patients receiving atypical antipsychotic therapy,
England and Wales has set mental health services the         but other studies suggest a direct effect of clozapine
target of reducing suicides by at least one-fifth by 2010    and olanzapine on lipid levels not associated with
(Department of Health, 1999). At present, 10–13% of          weight gain (Meyer, 2001).
people with schizophrenia die by suicide. Fontaine              The exact biochemical locus at which atypicals
et al estimated that the use of clozapine for schizo-        exert their influence on triglyceride metabolism
phrenia over a 10-year period would prevent 492              remains a source of speculation. However, it has been
deaths from suicide per 100 000 patients; unfor-             noted that the atypicals that exert significant effects
tunately, these would be offset by 416 deaths due to a       on fasting triglyceride levels are dibenzodiazepine-
presumed clozapine-induced weight gain of 10 kg.             derived compounds – clozapine, olanzapine and

128                                     Advances in Psychiatric Treatment (2005), vol. 11.
                                                                  Lifestyle and physical health in schizophrenia

quetiapine. They have the propensity to increase            on the USA’s Schizophrenia Patient Outcomes
serum triglyceride levels with lesser effects on            Research Team (PORT) and National Health Inter-
cholesterol (Meyer, 2001).                                  view Survey, studied the prevalence and correlates
                                                            of diabetes in people with schizophrenia. The PORT
                                                            survey interviewed 719 people with schizophrenia
Diabetes                                                    (mean age 43 years) about their physical health
                                                            between 1991 and 1996. It found 14.9% life-time
Diabetes is a growing problem in the general popu-          diabetes and 10.8% self-reported current diabetes.
lation: type II diabetes mellitus currently affects about   This compared poorly with general population data
2% of people in the UK. Risk factors for the disorder       from the National Health Interview Survey, in which
are shown in Box 5. Type II diabetes (non-insulin           diabetes rates in the general population were 1.2%
dependent) is associated with decreased sensitivity         (18- to 44-year-olds) and 6.3% (45- to 64-year-olds).
to the actions of insulin (insulin resistance), together    Thus, in the USA in the mid-1990s (probably before
with a variable and usually progressive defect in β-        the widespread use of atypical antipsychotics) the
cell function leading to a relative insulin deficiency.     rate of diabetes in people with schizophrenia already
Type I diabetes mellitus is a primary β-cell defect         exceeded that in the general population.
causing failure to secrete insulin – a condition not           Two more studies echo these results. Ryan et al
generally associated with schizophrenia.                    (2003) reported that more than 15% of their sample
   Diabetic ketoacidosis is an uncommon compli-             of drug-naïve patients with first-episode schizo-
cation of diabetes mellitus; more common complica-          phrenia had impaired fasting glucose compared
tions include microvascular disease (e.g. retinopathy,      with none of the matched healthy volunteers. In
nephropathy, neuropathies) and macrovascular                addition, a small study by Mukherjee et al (1996)
disease (e.g. cardiovascular and cerebrovascular            reported a family history of type II diabetes in 18–
disease). Hyperglycaemia involving glucose levels           19% of their sample of people with schizophrenia.
low enough to fall below the diagnostic threshold
for diabetes has been associated with increased             Risk factors
vascular morbidity and mortality in patients treated
with antipsychotics (Newcomer et al, 2001).                 The biggest risk factor for emergent diabetes in
                                                            schizophrenia is weight gain caused by anti-
                                                            psychotics. This has been clearly described for
Diabetes in schizophrenia                                   conventional antipsychotics and has become a focus
                                                            of much investigation for the atypical agents
Hyperglycaemia is an underrecognised comorbid               (Sussman, 2001).
complication of treatment with antipsychotic                   It is possible that other factors are associated with
medication and it may contribute to the increased           an increased prevalence of type II diabetes in people
morbidity and mortality seen in schizophrenia               with schizophrenia; these might include diet, lifestyle
(Tardieu et al, 2003). Dixon et al (2000), reporting        and behaviour, as well as a genetic predisposition
                                                            that may be shared with the disorder itself.
                                                               Since 1994, several case reports and uncontrolled
  Box 5 Risk factors for type II diabetes                   studies have linked the atypical antipsychotic
  Intrinsic risk factors                                    clozapine with the development of diabetes mellitus.
  •  Family history                                         A recent naturalistic uncontrolled follow-up study
  • Age greater than 45 years
                                                            of 82 people (mean age 36.4 years; mean BMI = 26.9)
  • Ethnicity (increased risk for Black and
                                                            starting clozapine reported that 36.6% (30/82)
     minority ethnic groups)                                developed diabetes during the first 5 years of
  • Previous history of glucose intolerance
                                                            treatment (Henderson et al, 2000).
                                                               It has been hypothesised that diabetes occurs
  Modifiable risk factors                                   secondary to the often substantial weight gain with
  • Dyslipidaemia
                                                            antipsychotics. However, it seems that the atypical
  • Lack of exercise
                                                            antipsychotics may also contribute more directly to
  • Hypertension
                                                            the pathogenesis of hyperglycaemia. There have
  • Obesity
                                                            been several case reports and warnings by the UK’s
  Less-well established risk factors                        Committee on Safety of Medicines associating
  • Serious psychiatric illness                             olanzapine with acute-onset diabetes. Most, but
  • Alcohol misuse                                          interestingly not all of these patients experienced
  • Diet                                                    significant weight gain shortly after commencing
  • Hyperprolactinaemia                                     treatment. Of note, a case series of four patients
                                                            reported reduced glycaemic control with clozapine

Advances in Psychiatric Treatment (2005), vol. 11. http:/                                                       129
Connolly & Kelly

                                                            pituitary sensitivity to gonadotropin-releasing
  Box 6 Core features of metabolic syndrome                 hormone in women, affecting reproductive function
  •   Obesity – central or upper body                       and causing oligo- and amenorrhoea. Hypo-
  •   Insulin resistance or hyperinsulinaemia               oestrogenism comparable to postmenopausal status
  •   Dyslipidaemia                                         can occur and may predispose women to cardio-
  •   Impaired glucose tolerance or type II diabetes        vascular disease. In men there is reduced steroido-
      mellitus                                              genesis and spermatogenesis.
  •   Hypertension                                             Reduced bone mineral density in patients with
                                                            hyperprolactinaemia may be caused directly or (due
                                                            to hypogonadism) indirectly. Risk factors for the
not related to weight gain. One study of patients on        development of osteoporosis and the potential impact
antipsychotics showed that 29 out of the 30 cases of        of antipsychotics have been reviewed by Naidoo et al
diabetes diagnosed were identified at a routine             (2003) and are outlined in Box 7. Peak bone mass is
annual screening of fasting plasma glucose,                 established in the first two decades of life, and
illustrating the need for regular biochemical               antipsychotic medication at this stage could there-
monitoring (Meyer, 2001).                                   fore have long-lasting effects on bone mineral density.
   Diabetes is a chronic disease that requires active
self-care for optimal management; in view of the
cognitive, social and psychological disabilities of         Morbidity and mortality
people with schizophrenia, optimal care is often            in schizophrenia
                                                            The impact of deinstitutionalisation on mortality
                                                            rates has been studied in Norway (Hansen et al, 2001)
Metabolic syndrome                                          and Finland (Salokangas et al, 2002). In Norway, all-
                                                            cause mortality rates for people with functional
In a detailed review by Ryan & Thakore (2002),              psychosis increased significantly between 1980 and
evidence is presented suggesting that aspects of            1992 (compared with the 1950s and 1960s), the
metabolic syndrome (Box 6) exist in patients with           period during which deinstitutionalisation took
schizophrenia. They highlight the potential role of         place. In Finland, however, although mortality rates
visceral fat as a common pathological factor in             were higher than population norms for the study
explaining some types of cancer, cardiovascular             period of 1982 to 1994 (during which time psychiatric
illness, type II diabetes mellitus and dyslipidaemia        beds were more than halved), there was no increased
in patients with schizophrenia. In a subsequent             mortality for patients with schizophrenia. No
study, Thakore and colleagues report findings               comparison was made with earlier time periods.
that drug-naïve and drug-free patients had more
than three times the visceral fat found in matched
controls using computed tomography (Thakore et
                                                              Box 7 Potential risk factors for osteoporosis
al, 2002). By comparison, in a controlled study of
                                                              in schizophrenia (after Naidoo et al, 2003)
drug-naïve Chinese patients that used magnetic
resonance imaging, Zhang et al (2004) found only              Factors due to schizophrenia itself
slight elevations in fat indicators at baseline, but          • Poor diet
significantly increased subcutaneous and intra-               • Limited weight-bearing exercise
abdominal fat following 10 weeks of treatment                 • Smoking (has a direct toxic effect on
mostly with chlorpromazine and risperidone                      osteoblasts)
   Lifestyle factors associated with metabolic                • Polydipsia
syndrome (such as increased dietary fat content,
                                                              Factors due to antipsychotic treatment
reduced physical activity, smoking, excess alcohol
                                                              • Hyperprolactinaemia
consumption and other endocrine and cardio-
                                                              • Secondary lowered oestrogen
vascular factors) are clearly in evidence in some
                                                              • Secondary lowered testosterone
patients with schizophrenia.
                                                              Other factors influencing risk of fracture
                                                              • Sedation
Prolactin elevation                                           • Orthostatic hypotension

                                                              • Dizziness and falls
Conventional antipsychotics and, of the atypicals,            • Postmenopausal status
risperidone in particular, can have deleterious effects       • Anticonvulsants
on sexual and endocrine function (Meaney &                    • Corticosteroids
O’Keane, 2002). Raised prolactin levels reduce

130                                    Advances in Psychiatric Treatment (2005), vol. 11.
                                                                         Lifestyle and physical health in schizophrenia

   The relationship between quality of care and                       So what of the future? Our view is that the
mortality rates for cardiovascular disease in older                evaluation of new therapies should include detailed
patients with schizophrenia has been studied by                    assessments of physical health and future risk
Druss et al (2001). They have shown that the excess                estimates in addition to standard psychiatric out-
mortality rates for these patients after myocardial                comes. Psychiatrists must ensure that they arrange
infarction were reduced in magnitude and became                    the appropriate examination and investigation of
non-significant when adjustment was made for the                   patients at risk of developing significant physical
presence or absence of quality measures such as                    morbidity, working closely with general practitioners
reperfusion therapy, use of aspirin, beta-blockers or              and with other specialists when appropriate. The
angiotensin-converting enzyme (ace) inhibitors, and                advantages of atypical drugs are clear, but psy-
smoking cessation therapy. The study does not                      chiatrists should weigh up the risks of metabolic
clarify whether differences in the provision of quality            disturbance and its potential impact on future
of care to these psychiatric patients are due to patient           cardiovascular risk when selecting an antipsychotic
or provider factors.                                               for a specific patient. They should take a careful
   Psychotropic medication in the treatment of                     medical history and be prepared to monitor weight
schizophrenia can exert a number of cardiovascular                 and other metabolic markers (such as glucose and
effects. The safer selection of these drugs for                    lipid profile) over time. This information will help
vulnerable patients has been the subject of a                      clinicians analyse the risks and benefits of a specific
previous APT review (O’Brien & Oyebode, 2003).                     treatment for an individual patient.
                                                                      The challenge for all is to ensure that the physical
                                                                   health of patients with schizophrenia is given the
The future                                                         priority it deserves, helping them to face their future
In considering what to do about the poor physical                  with the lowest possible morbidity and mortality
health of people with schizophrenia, we must first                 odds stacked against them.
take account of their own opinions. Many rate
physical health as a high priority and the more
physical conditions they have, the poorer their
                                                                   References and further articles
satisfaction with their physical and mental health                 Allison, D. B. & Casey, D. E. (2001) Antipsychotic-induced
(Dixon et al, 1997).                                                 weight gain. A review of the literature. Journal of Clinical
                                                                     Psychiatry, 62 (suppl. 7), 22–31.
   That the excess mortality from natural causes in                Aronne, L. J. (2001) Epidemiology, morbidity, and treatment
schizophrenia may be contributed to by an un-                        of overweight and obesity. Journal of Clinical Psychiatry, 62
healthy lifestyle and might therefore be amenable to                 (suppl. 23), 13–22.
                                                                   Brown, S. (1997) Excess mortality of schizophrenia. A meta-
health promotional interventions is not in dispute.                  analysis. British Journal of Psychiatry, 171, 502–508.
But inducing change may not be easy. The extent of                 Brown, S., Birtwistle, J., Roe, L. et al (1999) The unhealthy
the contribution of the illness itself (either through               lifestyle of people with schizophrenia. Psychological Medicine,
                                                                     29, 697–701.
positive, negative or cognitive symptoms) and of any               Department of Health (1999) Saving Lives: Our Healthier Nation.
biological predisposition is not clear, but is not so                London: Stationery Office.
small as to be rendered insignificant. Furthermore,                Dixon, L., Postrado, L., Delahauty, J., et al (1997) The
                                                                     association of medical co-morbidity in schizophrenia with
the additional risks to physical health potentially                  poor physical and mental health. Journal of Nervous and
induced by the complex interplay of medication and                   Mental Disease, 187, 496–502.
specific predispositions to metabolic disorders                    Dixon, L., Weiden, P., Delahanty, J., et al (2000) Prevalence
                                                                     and correlates of diabetes in national schizophrenia
cannot be ignored. Psychiatric training may not                      samples. Schizophrenia Bulletin, 26, 903–912.
equip psychiatrists to adequately examine and                      Druss, B. G., Bradford, W. D., Rosenheck, R. A., et al (2001)
investigate the physical health of their patients.†                  Quality of medical care and excess mortality in older
                                                                     patients with mental disorders. Archives of General Psychiatry,
However, it remains the psychiatrists’ responsibility                58, 565–572.
to be aware of the health consequences of psychiatric              Fontaine, K. R., Moonseong, H., Harrigan, E. P., et al (2001)
disorder and the treatments they initiate.                           Estimating the consequences of antipsychotic induced
                                                                     weight gain on health and mortality rate. Psychiatric Research,
   People with schizophrenia may fail to recognise                   101, 277–288.
the early signs of physical ill health or avoid contact            Gopal, Y. V. & Variend, H. (2005) First-episode schizophrenia:
with health services. The traditional routes to obtain-              review of cognitive deficits and cognitive remediation.
                                                                     Advances in Psychiatric Treatment, 11, 38–44.
ing healthcare may prove too complex for someone                   Hansen, V., Jacobsen, B. K. & Arnesen, E. (2001) Cause-specific
who is chronically distressed by positive symptoms,                  mortality in psychiatric patients after deinstitutionalisation.
cognitively impaired or lacking the motivation                       British Journal of Psychiatry, 179, 438–443.
                                                                   Henderson, D. C., Cagliero, E., Gray, C., et al (2000) Clozapine,
required to make and attend an appointment.                          diabetes mellitus, weight gain, and lipid abnormalities.A
                                                                     five-year naturalistic study. American Journal of Psychiatry,
  For a discussion of shared care for people with mental illness     157, 975–981.
 see pp. 133–141, this issue. Ed.                                  Hilger, E., Quiner, S., Ginzel, I., et al (2002) The effects of
                                                                     orlistat on plasma levels of psychotropic drugs in patients

Advances in Psychiatric Treatment (2005), vol. 11. http:/                                                                      131
Connolly & Kelly

  with long-term psychopharmacotherapy. Journal of Clinical          Zhang, Z.-J., Yao, Z.-J., Liu, W., et al (2004) Effects of
  Psychopharmacology, 22, 68–70.                                       antipsychotics on fat deposition and changes in leptin and
Jablensky, A. (1999) Schizophrenia: epidemiology. Current              insulin levels. Magnetic resonance imaging study of
  Opinion in Psychiatry, 12, 19–28.                                    previously untreated people with schizophrenia. British
Joukamaa, M., Heliovaara, M., Knekt, P., et al (2001) Mental           Journal of Psychiatry, 2004, 184, 58–62.
  disorders and cause specific mortality. British Journal of         Zimmerman, U., Kraus, T., Himmerich, H., et al (2003)
  Psychiatry, 179, 498–502.                                            Epidemiology, implications and mechanisms underlying
Joy, C. B., Mumby-Croft, R. & Joy, L. A. (2003) Poly-                  drug-induced weight gain in psychiatric patients. Journal of
  unsaturated fatty acid supplementation for schizophrenia.            Psychiatric Research, 37, 193–220.
  Cochrance Library, issue 2. Oxford: Update Software.
Kelly, C. & McCreadie, R. (2000) Cigarette smoking and schizo-
  phrenia. Advances in Psychiatric Treatment, 6, 327–332.
Kerwin, R. W. & Bolonna, A. (2005) Management of clozapine-
  resistant schizophrenia. Advances in Psychiatric Treatment,
  11, 101–106.                                                       1   Core features of the metabolic syndrome include:
Kurzthaler, M. D. & Fleischhacker, W. W. (2001) The clinical         a   hyperinsulinaemia
  implications of weight gain in schizophrenia. Journal of           b   raised blood pressure
  Clinical Psychiatry, 62 (suppl. 7), 32–37.                         c   coronary heart disease
Leask, S. J. (2004) Environmental influences in schizophrenia:
                                                                     d   central obesity
  the known and the unknown. Advances in Psychiatric
  Treatment, 10, 323–330.                                            e   type I diabetes.
McCreadie, R. G. (2003) Diet, smoking and cardiovascular
  risk in people with schizophrenia. Descriptive study. British      2   People with schizophrenia have an increased rate of:
  Journal of Psychiatry, 183, 534–539.                               a   premature death
McCreadie, R. G. (2004) Editorial: Schizophrenia revisited.          b   asthma
  Advances in Psychiatric Treatment, 10, 321–322.
McCreadie, R. G., MacDonald, E., Blacklock, C., et al (1998)
                                                                     c   heart disease
  Dietary intake of schizophrenia patients in Nithsdale,             d   smoking
  Scotland: Case Control Study. BMJ; 317, 784–785.                   e   rheumatoid arthritis.
Meaney, A. M. & O’Keane, V. (2002) Prolactin and
  schizophrenia. Clinical consequences of hyperprolactin-            3 The following statements are true for schizophrenia:
  aemia. Life Sciences, 71, 979–992.                                 a compared with males, females have a higher
Meltzer, H. Y. & Fleischhacker, W. W. (2001) Weight gain: a
  growing problem in schizophrenia management. Journal of              prevalence of cigarette smoking
  Clinical Psychiatry, 62 (suppl. 7), 1–43.                          b compared with males, females have a higher
Meyer, J. M. (2001) Effects of atypical antipsychotics on weight       prevalence of obesity
  and serum lipid levels. Journal of Clinical Psychiatry, 62         c people with schizophrenia begin to smoke at a
  (suppl. 27), 27–34.
                                                                       significantly earlier age than the general population
Mukherjee, S., Decins, P., Bocola, V., et al (1996) Diabetes
  mellitus in schizophrenic patients. Comprehensive Psychiatry,      d people with schizophrenia have lower rates of
  37, 68–73.                                                           smoking-related illness
Naidoo, U., Goff, D. C. & Klibanski, A. (2003) Hyperprolactin-       e the majority of people with schizophrenia have no
  aemia and bone mineral density: the potential impact of              interest in altering their smoking behaviour.
  antipsychotic agents. Psychoneuroendocrinology, 28 (suppl.
  2), 97–108.
Newcomer, J. W., Haupt, D. W., Fucetola, R., et al (2001)
                                                                     4 Risk factors for osteoporosis with schizophrenia
  Metabolic disturbances associated with antipsychotic use.            include:
  Journal of Clinical Psychiatry, 61 (suppl. 27), 1–43.              a obesity
O’Brien, P. & Oyebode, F. (2003) Psychotropic medication             b poor nutrition
  and the heart. Advances in Psychiatric Treatment, 9, 414–423.      c smoking
Rowlands, P. (2004) The NICE schizophrenia guidelines: the
  challenge of implementation. Advances in Psychiatric               d antipsychotic treatment
  Treatment, 10, 403–412.                                            e polydipsia.
Ryan, M. C. M. & Thakore, J. H. (2002) Physical consequences
  of schizophrenia and its treatment. The metabolic                  5   Atypical antipsychotics are associated with:
  syndrome. Life Sciences, 71, 239–257.                              a   increased smoking rates
Ryan, M. C. M., Collins, P. & Thakore, J. H. (2003) Impaired
                                                                     b   increased weight
  fasting glucose tolerance in first episode, drug naïve patients
  with schizophrenia. American Journal of Psychiatry, 160, 284–      c   increased blood sugar
  289.                                                               d   decreased extrapyramidal side-effects
Salokangas, R. K., Honkonsen, T., Stengard, E., et al (2002)         e   decreased quality of life.
  Mortality in chronic schizophrenia during decreasing
  number of psychiatric beds in Finland. Schizophrenia
  Research, 54, 265–275.
Singh, S. P. & Fisher, H. L. (2005) Early intervention in
  psychosis: obstacles and opportunities. Advances in
  Psychiatric Treatment, 11, 71–78.                                      MCQ answers
Sussman, N. (2001) Review of atypical antipsychotics and
  weight gain. Journal of Clinical Psychiatry, 62 (suppl. 23), 5–        1          2           3           4           5
Tardieu, S., Micallef, J., Gentile, S., et al (2003) Weight gain         a   T      a   T       a   F       a   F       a   F
  profiles of new anti-psychotics: public health consequences.           b   T      b   F       b   T       b   T       b   T
  Obesity Reviews, 4, 129–138.                                           c   F      c   T       c   F       c   T       c   T
Thakore, J. H., Mann, J. N, Vlahos, I., et al (2002) Increased
  visceral fat distribution in drug-naïve and drug-free patients         d   T      d   T       d   F       d   T       d   T
  with schizophrenia. International Journal of Obesity and Related       e   F      e   F       e   F       e   T       e   F
  Metabolic Disorders, 26, 137–141.

132                                            Advances in Psychiatric Treatment (2005), vol. 11.

To top