Medical Morbidity and Mortality
Essential Concepts
Physical health and wellness matter as much as mental health to patients with schizophrenia. Reducing premature deaths from cardiac disease is an important treatment goal.
Routine health monitoring in conjunction with primary care to prevent medical morbidity and mortality should be implemented. This includes preventive health care (e.g., eye examinations colonoscopy), vaccinations (e.g., influenza), and screening for infectious diseases (e.g., human immunodeficiency virus [HIV], hepatitis).
Seven of ten patients with schizophrenia smoke. To reduce cardiovascular mortality and lung diseases, help patients quit.
Four of ten patients with schizophrenia have the metabolic syndrome. Preventing weight gain and the metabolic syndrome are important to reduce cardiac mortality. Weight control requires lifestyle modification.
Switching antipsychotics for metabolic reasons is a decision that must take into account the risk of psychiatric instability.
“Mens sana in corpore sano.”
“A sound mind in a sound body.”
—Juvenal, Roman poet, late 1st and early 2nd century
It has been estimated that having schizophrenia shortens average life expectancy by at least 15 years. Although some of the excess mortality comes from suicide, cardiovascular disease has emerged as the most important cause of premature death. In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), patients had a fourfold increased 10-year cardiac risk over the general population, with higher rates of several major cardiac risk factors (smoking, diabetes, hypertension, and low high-density lipoprotein, or HDL) (Goff et al., 2005a). Consequently, the role of the psychiatrist can no
longer be simply to keep patients out of psychiatric hospitals. Instead, addressing modifiable cardiovascular disease risk factors, particularly smoking and obesity (with its associated metabolic syndrome), have become an important aspect of psychiatric care for patients with schizophrenia. With poor physical health, your patient might die mentally well, but at an early age (the proverbial operation that was a success but the patient died).
longer be simply to keep patients out of psychiatric hospitals. Instead, addressing modifiable cardiovascular disease risk factors, particularly smoking and obesity (with its associated metabolic syndrome), have become an important aspect of psychiatric care for patients with schizophrenia. With poor physical health, your patient might die mentally well, but at an early age (the proverbial operation that was a success but the patient died).
Focusing on physical health early, when patients start taking medications, might prevent some of the morbidity that we see in today’s cohort of middle-aged patients.
TIPCalculate each patient’s 10-year Framingham cardiac risk (see Additional Resources). An increased risk might motivate some patients to quit smoking and change their lifestyle.
ROUTINE HEALTH MONITORING
Concern yourself with the physical health of your patients. As a psychiatrist, you often have much more contact with a psychiatric patient than does the primary care physician (PCP), and you might be in a much better position to monitor physical health and to advise behavioral changes. I suggest that you assume primary responsible for at least two aspects of physical health: smoking cessation and monitoring the effects of the medications that you prescribe, especially weight gain and metabolic problems.
Record the following medical information in every patient chart:
Smoking status as a “vital sign” (e.g., 1 pack per day); note nicotine dependence, if present.
Body mass index (BMI), not just weight; note if overweight or obese.
Dyslipidemia, diabetes, or hypertension, if present (See WELL CARD Dyslipidemia, Hyperglycemia, Hypertension in Appendix C).
Metabolic syndrome, if present (see WELL CARD Metabolic Syndrome in Appendix C).
Activity level (e.g., inactive, walks, exercises three times a week).
If you detect a medical problem, you can treat what you are comfortable with or defer to a PCP. Even if your patient has a PCP, there is no harm in reinforcing the need for preventive screening (e.g., eye examinations or colonoscopy), reviewing vaccination requirements (e.g., influenza vaccine in the fall), or suggesting testing for infectious diseases when indicated (e.g., tuberculosis, hepatitis C virus, HIV). Your patients might trust your advice more than you realize, and your intervention might actually lead to their accessing some preventive health care.
TIP
