Causes of Medical Mortality

All the major cardiac risk factors (smoking, diabetes, hypertension, dyslipidemia) are highly prevalent in patients with schizophrenia [11]. In a typical sample of chronic schizophrenia patients, between 40 and 60% of patients are diagnosed with the metabolic syndrome. In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), the increased prevalence of risk factors translated into a fourfold increased 10-year cardiac risk over the general population [12]. It is particularly concerning that cardiac risk factors are already present in young, first-episode patients. In the RAISE sample, for example, 13% of patients who were on average 24 years old already had the metabolic syndrome; half the patients smoked, and half were obese [13]. Focusing on physical health early, when patients start taking medications, might prevent some of the morbidity and mortality that we see in today’s cohort of middle-aged and older patients.

Medical Prevention Mind-Set

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. The extent of your involvement in medical aspects of your patient’s care is going to be determined by your training, the local resources, a patient’s preference, and ultimately how you define your role. The American Psychiatric Association’s position is clear: some medical aspects of care are essential components of psychiatric practice (APA) [14]. Without psychiatric leadership, the gap in life expectancy will not be reduced.

The American Psychiatric Association has developed a grid that delineates the role of the psychiatrist vis-à-vis medical care, centered around the acuity of the medical problem and medical resources available [15]. For most medical problems (e.g., dyslipidemia or diabetes), your role will usually be small unless you happen to be trained in both psychiatry and medicine; most psychiatrists will not manage acute medical issues or take on chronic care tasks. However, awareness of medical issues and intervening if needed may well fall into your scope of responsibilities. Simply linking a patient to primary care is often all that is needed. Sometimes, you may need to go the proverbial extra mile: not receiving standard medical care for diagnosed conditions (e.g., cardioprotective medications after a heart attack) is one factor that contributes to the increased mortality in patients with schizophrenia [16]. Advocating for your patients to receive optimal medical care may be needed if we want to close the aforementioned mortality gap [17].

If you detect a medical problem incidentally or because of metabolic screening, you can decide to 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 cancer screenings like a colonoscopy or mammography), 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) [18]. Your patients might trust your advice more than you realize, and your verbal intervention might actually lead to their accessing some preventive healthcare. Many chronic patients have community-based case workers who could be engaged to make PCP appointments or cancer screening tests happen.

For blood-borne infections (hepatitis C and HIV), the identification of infected patients via screening is a critical first step in the so-called cascade of care (identifying patients, linking them to care, starting treatment, persisting with treatment to achieving desired health outcome) [19]. Routine screening for HIV (regardless of risk factors) and HCV screening (based on risk factors and cohort screening) as recommended by the CDC can easily be incorporated into clinic workflows for new patients. Both HIV and hepatitis C care have been revolutionized when highly effective antiviral treatments became available. In the case of hepatitis C, a short course with well-tolerated direct-acting antivirals can now eradicate the virus from a patient’s blood stream [20]. Screening is particularly rewarding for medical conditions where treatment makes a real difference, as is the case for those two blood-borne infections (see case at the end of the chapter). Moreover, identifying infected patients who are unaware reduces secondary infections which is an important infection control goal for public health authorities.

I suggest that you assume primary responsibility for at least two aspects of physical health: smoking cessation and monitoring the side effects of the medications that you prescribe, especially antipsychotic-associated weight gain and metabolic problems (i.e., metabolic screening). In a survey at our hospital, the primary care doctors very strongly believed that managing smoking cessation falls under psychiatry’s purvey [21].

Metabolic Disease Prevention

Helping patients maintain a normal weight or lose excess weight is probably the most vexing and maddening medical problem that you will be trying to address. The importance of preventing weight gain or promoting weight loss lies in avoiding the downstream medical consequences of being overweight or obese, particularly the metabolic syndrome. Obesity causes a host of other complications beyond the metabolic syndrome that adversely affect quality of life (e.g., daytime sedation from obstructive sleep apnea).

A cynic might say that we have no tool to prevent weight gain – the rates of obesity in the United States keep increasing every year in every state, despite billions spent on “healthier” food and weight loss drugs. You are trying to prevent weight gain against this background of an ever-increasing BMI in the general population; and you are attempting this in a population that might be less equipped to do so, on account of disease-intrinsic motivational deficits or poverty. It is an uphill battle.

To add insult to injury, our medications clearly exacerbate any such weight gain that might occur naturally. Almost all antipsychotics show weight gain after extended use [22]. In a meta-analysis, only ziprasidone did not cause weight gain [23]. The weight gain is more pronounced in younger and antipsychotic-naïve patients [24]. Antipsychotic-induced weight gain is not clearly dose-dependent: lowering the dose is therefore usually not a successful management strategy. I find it useful to view psychotropics as one more risk factor toward weight gain that patients must take into account (as opposed to attributing all and any weight gain to medications alone). For more details about antipsychotic-associated weight gain, see Chap. 13.

With a metabolic prevention mind-set, you prefer antipsychotics with the least liability toward weight gain to prevent added iatrogenic morbidity; you screen and monitor to detect, and you prevent/blunt weight gain in order to mitigate by intervening early and proactively.

Preventing Metabolic Problems (Primary Prevention)

Choose your antipsychotic wisely: select an antipsychotic with a lower liability for weight gain. The partial agonist antipsychotics (brexpiprazole [25], cariprazine [26], and aripiprazole [24]), lurasidone [27], and ziprasidone [23] appear to be safest in this regard. Suffice it to say that this is not always possible: our most effective antipsychotics, olanzapine and clozapine, are also the most problematic ones with regard to weight gain [28].

I listed the addition of metformin below, under secondary prevention although it can be added from the get-go, before weight gain or metabolic abnormalities have occurred. The distinction between primary and secondary prevention is not clear-cut since when a disease begins is only categorical in the minds of people who develop disease classifications.

Introduce ancillary nonmedical prevention efforts (diet and exercise) early, and make illness self-management part of your treatment plan. Exercise should be supported (a sibling will do) exercise. It cannot simply left up to the patient’s motivation. Without your patient making some therapeutic lifestyle changes (TLC), the new term for “diet and exercise,” it will be very difficult to treat obesity successfully. While you want to be an advocate for healthy living, guard against becoming a crusader for better-than-well [29]. Patients should not lose weight to please you. You cannot give them the impression that failure to lose weight is a personal insult to you and causes you to be disappointed in them. Weight loss in and of itself is also not the goal; healthier living and increasing fitness are. Thus, do not focus on simply how much weight was lost but how the efforts of better eating and of more walking are beneficial, including for a sense of mastery. It is very encouraging that behavioral interventions to manage weight gain can be successful in patients with serious mental disorders [30]. Core interventions used in a behavioral intervention trial known as STRIDE that helped patients succeed in losing weight included increasing awareness through monitoring, creating personalized diet and exercise plans, reducing calories, improving diets, increasing physical activity, and graphing progress [31]. Personalizing interventions appears to be critical for long-term success [32].

However, much more work remains to be done. The health results of a multicomponent workplace wellness program have been disappointing [33]. A well-conducted trial in obese patients with schizophrenia termed CHANGE similarly failed to show cardiovascular benefits from individual lifestyle coaching over treatment as usual [34]. Last, the role of digital medicine to track behaviors (e.g., counting steps) in order to encourage behavioral change may have been oversold [35]. Together, these results that run counter to our intuition to recommend “lifestyle modifications” should give us pause before uncritically rolling out “wellness programs” for our population.

In the interim, I would encourage the following six behavioral changes that would have a positive effect in the long term, if implemented and sustained.

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  Have patients weigh themselves every week to catch small but steady weight gain.

  
  
• 
  

  Normal portions for whatever is eaten. Teach patients about portion size so they appreciate how much they consume. Do not micromanage what they eat.

  
  
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  Stimulus control. It might be simpler to ban some food items from entering the house than trying to control the amount eaten.

  
  
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  No deserts. (As a compromise for New England, limit donuts to once a week for breakfast).

  
  
• 
  

  No soft drinks but water instead.

  
  
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  Alcohol only in moderation. Teach patients about the additional calories from drinking alcohol regularly.

Tip

Get your patient to be more active. Stress the benefits of an active lifestyle to the patient (including for cognition) [36]. Regular exercise even in the absence of weight loss can improve the metabolic syndrome [37]. Always be reasonable: How likely is it that a person who never ran a mile in his life will start jogging regularly? Perhaps the person used to swim and can join the local YMCA again. Perhaps taking the stairs instead of the elevator can literally be the first step. Wearing a device that counts steps can concretely offer feedback about actual activity levels.

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