Physical Health and Schizophrenia
Physical Health in People with Schizophrenia
Without a doubt physical health is a problem for people with schizophrenia and whilst the focus of health professionals traditionally has been to minister to the mental health needs, the cost of physical illnesses to those living with schizophrenia and the wider society in premature death, serious illness and poor quality of life has long been under-rated.
The average life expectancy of people living with schizophrenia is about 10 to 20 years less than that of the general population2 and research has shown quite conclusively that people with schizophrenia have increased rates of physical illnesses; in fact over 75% of people with a diagnosis of schizophrenia have at least one chronic physical condition running alongside their schizophrenia and the more severe the schizophrenia is the more severe their physical problems are also likely to be3.
Thus it is clear that, even allowing for suicide (about 10% of people with a diagnosis of schizophrenia will die by their own hand within ten years of diagnosis9), the mortality rate for people with schizophrenia is higher.
The range of illnesses that afflict people with schizophrenia disproportionately is very wide and includes the more obvious candidates like heart disease, stroke and diabetes but also high blood pressure, some cancers, sexual dysfunction, osteoporosis and infectious diseases like HIV, TB and hepatitis3,12.
In addition to being more prone to physical illnesses, people with schizophrenia tend to experience physical health problems at a younger age than other people. In fact in the 25 to 44 age group people with schizophrenia are five times more likely to have a heart problem than someone in the general population3.
Caring for the Physical Health of People with Schizophrenia
In February 2015, NICE the UK body which sets treatment standards for medical treatment, published a set of new quality standards which specifically addressed the problem of poor physical health in people with schizophrenia. Amongst other standards NICE lays down that people with schizophrenia should now have specific physical health assessments and be given help with healthy eating, physical activity programmes and stopping smoking.
It is to be hoped that this fresh approach will improve care in the NHS as previously the NHS has not been particularly good at looking after the physical health of people with a diagnosis of schizophrenia. In a recent audit of schizophrenia treatment standards in the NHS only about one third of people with schizophrenia had had their physical health properly monitored by their GP and in two thirds of cases where monitoring did pick up a problem such as abnormal blood sugar (which may indicate diabetes) nothing was done about it1.
The Mental Health Service may be no better in this respect. A recent editorial in the Lancet, the doctor’s journal, drew attention to a “worrying” lack of training in physical health needs amongst psychiatrists and psychiatric nurses14.
Lack of attention by the health care professionals to people’s physical health needs is a source of some dissatisfaction amongst people living with schizophrenia. In fact in a recent study over half of those questioned said that they were dissatisfied with this aspect of their health care7.
Common Physical Health Problems in People with Schizophrenia
Obesity (Weight Gain)
Obesity is one of the biggest physical health challenges affecting people with schizophrenia10 and along with obesity go the obesity-related cancers12. From obesity springs a whole host of other chronic problems with serious implications for life expectancy and quality of life.
Heart disease and stroke are both more common amongst people living with schizophrenia. Death from heart disease is about twice as common in people with schizophrenia as in the general population3.
Diabetes is more common amongst people with schizophrenia and although weight gain is implicated as the main culprit here, there is also some emerging evidence that some of the antipsychotic medicines used to treat the positive symptoms such as halucinations themselves may increase the risk of diabetes. Why this is so is not yet clear and there is currently intensive research being carried out on this subject. It may be due to antipsychotics altering the way that the body uses insulin, the hormone that regulates blood sugar level3.
There is also another interesting link between schizophrenia and diabetes. We have long known that the long term outcomes for people with schizophrenia in developing countries is better than that in the advance industrial countries despite the better health care available in the developed world. It also happens that the incidence of diabetes in these developing countries is also lower. Some have speculated that it is access to useful occupation in subsistence farming, fishing etc that is at work in improving the outcomes and it could also be the case that this same increased level of activity helps to protect against diabetes.
Recently there has been some interest in the existence of a genetic link between diabetes and schizophrenia and a study carried out at the University of Massachusetts Medical School in the US has claimed to establish such a link. Again, although interesting in itself, this is an area that requires much greater study before any firm conclusion can be reached.14
Viral diseases such as HIV and Hepatitis both afflict people with schizophrenia disproportionately and are probably associated with intravenous drug use and the unsafe sexual practices which go along with street drug use12 which are sadly problems that also seem to be associated with schizophrenia. In fact over half of people with schizophrenia will also abuse alcohol or street drugs.
There is some research evidence indicating that people with schizophrenia tend to suffer more from osteoporosis (a condition which causes a progressive weakening of the bones). This has two possible causes. The first is the sedentary lifestyle and poor diet which many people with schizophrenia adopt with little if any of the sort of physical exercise that can help to maintain bone strength.
The second cause is the issue of hyperprolactinaemia – a raised level in the blood of the hormone prolactin. High levels of prolactin can cause feminising effects in men such as abnormal breast growth and lactation (producing milk from the breasts) and in the long term osteoporosis in both men and women3. The research evidence for this connection has been slightly contradictory but the weight of evidence does now seem to implicate the antipsychotics in this problem12.
It is true that there are other risk factors for osteoporosis such as age, being female and a family history of the condition and hyperprolactinaemia only adds to these other risks. Unfortunately, even if you are fortunate enough to have your physical health checked by your GP regularly they will not look at prolactin levels unless you ask them to4.
Having a raised prolactin level does not in itself mean that you will suffer from osteoporosis and if you think that you are at risk here, say because you have some of the other risk factors as well, then you should discuss it with your doctor and ask about periodic bone density testing. There is more about this on our advice sheet about side effects of antipsychotics.
Sexual problems such as lack of libido (sex drive), anorgasmia (difficulty in achieving orgasm) in men and women and erectile dysfunction (difficulty in achieving erections) in men are a problem associated with both the antipsychotics and antidepressants to some extent12.
The significance of these problems should not be seen as purely recreational. People with schizophrenia have a sex drive like all other human beings and cannot be blamed for seeking sexual fulfilment. It is no coincidence that, along with weight gain, sexual problems are probably one of the most frequently cited reasons for people with schizophrenia stopping their medication4. However, that said, it must be acknowledged that the dual problems of smoking and obesity will also exacerbate sexual problems.
There are also a number of other conditions that affect people with schizophrenia to a greater extent than is found in the population at large.
Dental health amongst people with schizophrenia is usually very poor. Poverty, smoking and a general unwillingness to present with physical health problems all undoubtedly contribute to this.
Some research has found a higher incidence of some autoimmune diseases such as multiple sclerosis and psoriasis amongst people with schizophrenia. It is not currently thought that this higher incidence is the result of suffering from schizophrenia but is nonetheless interesting.
In women with schizophrenia obstetric problems during pregnancy and birth also tend to be encountered more frequently12.
Principal Causes of Ill health in Schizophrenia
Whilst each health condition has its own distinct set of causes there are four issues which are common to most of the physical health problems faced by people with schizophrenia.
Sedentary (inactive) lifestyle
Much of the blame for physical ill health in schizophrenia can be put down to the sedentary (inactive) lifestyles that many people with schizophrenia lead. In the National Audit of Schizophrenia mentioned above, two thirds of those people questioned said that they were not actively looking for work1 and Warner estimates that only about 13% of people with a diagnosis of schizophrenia in the UK are in any kind of work6.
The link between physical activity and physical health is now well established. Regular and frequent physical exercise can reduce the risk of physical health problems in schizophrenia by half and can achieve considerable reduction in the risk of heart disease and diabetes even if you don’t manage to get your weight down,8. However the problem of obesity cannot in itself be ignored and does tend to affect people with schizophrenia disproportionately10.
Of course part of the reason for so many people with schizophrenia being overweight is the side effect of the antipsychotic medicines used to control the positive symptoms such as auditory hallucinations (hearing voices) but which also cause those treated with them to gain weight quite drastically. Why this is so is not yet clear. It may be that the antipsychotics have an effect on appetite and that people on them will tend to eat more or it may be that they cause the body to use food differently and so increase weight.
Not all of the antipsychotics have the same impact here: Olanzapine and Clozapine have been found to be the worst culprits, Aripiprazole, Amisulpride, Ziprasidone and Asenapine have little or no weight gain effect whilst Risperidone and Quetiapine lie somewhere in the middle causing some weight gain12.
But the antipsychotics cannot shoulder the whole burden of blame here as the excess mortality was clearly demonstrated in research studies carried out before the introduction of the antipsychotics in the 1950s10.
It has also been argued by some that it is the sedative effects of the antipsychotics that are the root cause of the lack of activity amongst people with schizophrenia again however a low level of physical activity was well established by research before the antipsychotics came into use and has been confirmed by more recent research since13.
Poor diet is also implicated in ill health. Studies have shown that people with schizophrenia have a poorer diet than the general population eating less fruit and vegetables, less fibre and less antioxidant vitamins and with higher levels of sugar and fat13.
People with schizophrenia tend also to be heavy smokers10. Around 70% of people with a serious mental illness are smokers compared to only around 25% in the general population11. This greatly impacts on their physical health and also reduces the effectiveness of some antipsychotic medicines resulting in a requirement for larger doses which in turn exacerbates the problem with weight gain. A secondary effect of smoking is to reduce disposable income which has a knock on effect on diet and access to discretionary health care such as dentists, opticians and counselling.
Reluctance to Engage
People with schizophrenia tend to be less willing to acknowledge the existence of physical health problems in themselves and to seek help with them when they arise. This reluctance to engage with health services may have its roots in residual psychotic symptoms, low self esteem or previous unpleasant experiences with health care professionals. It is important that we do not blame people with schizophrenia for this nor take the view that they are best left to their own devices. Access to health care is after all their right as much as that of any other citizen. Health care professionals, in particular GPs, must proactively seek regular and frequent contacts with their schizophrenia patients to assess physical health and intervene early on in the course of physical illness.
1. Healthcare Quality Improvement Partnership, 2014, Second National Audit of Schizophrenia: What You need to Know.
1. Chesney E, Goodwin G, Fazel S, 2014, Risks of All-cause and Suicide Mortality in Mental Disorders: a Meta-review, published in World Psychiatry.
2. Mitchell A, Malone D, 2006, Physical Health and Schizophrenia, published in Current Opinion in Psychiatry.
3. Author’s personal experiences.
4. Eaton W, Majella B, Ewald H,Ole M, Chuan-Yu C, Esben A,Preben M, 2006, Association of Schizophrenia and Autoimmune Diseases: Linkage of Danish National Registers, Published in the American Journal of Psychiatry.
5. Warner R, 2000, The Environment of Schizophrenia, Brunner Routledge.
6. Sane, 2014, Living with Schizophrenia: People’s Experience of the Condition.
7. Penedo F, Dahn J, 2006, Exercise and Wellbeing: A Review of Mental and Physical Health Benefits Associated with Physical Activity, published in Current Opinion in Psychiatry.
8. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial, P291.
9. Jouk M, Heliovaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V, 2006, Schizophrenia, Neuroleptic Medication and Mortality, published in the British Journal of Psychiatry.
10. Reveley A, 2007, Your Guide to Schizophrenia, Hodder Arnold, p103.
11. De Hert M, Correll C, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Moller H, Ndetel D, Newcomer J, Uwakwe R, Leucht S, 2011, Physical Illness in Patients with Severe Mental Disorders, published in World Psychiatry.
12. Peet M, 2004, Diet, Diabetes and Schizophrenia: Review and Hypothesis, published in the British journal of Psychiatry.
13. Lancet, 19th February 2011.
14. Jurczyk A, Nowosielska A, Przewozniak N, Arvee K, Dilorio P, Blodgett D, Yang C, Campbell Thompson M, Atkinson M, Shulz L, Rittenhouse A, Harlan D, Greiner D, Bortell R, Beyond the brain: disrupted in schizophrenia 1 regulates pancreatic β-cell function via glycogen synthase kinase-3β, Published in The Journal of the Federation of American Societies for Experimental Biology, November 2015.