Caring for mind and body: Medical monitoring and lifestyle training key to good health for people with schizophrenia: CrossCurrents Autumn 2003

CrossCurrents

Cindy McGlynn

The psychiatric symptoms of schizophrenia are so profound that physical health is often the last thing on the agenda when people with schizophrenia visit a doctor. Blood pressure check-ups, weight monitoring or glucose tests take a backseat to dealing with hallucinations, delusions and a host of other symptoms that can be part of the illness.

But poor physical health may be more dangerous to people with schizophrenia than their psychiatric symptoms. In fact, people with schizophrenia die 20 per cent earlier than the general population, according to Dr. Jonathan Meyer, an assistant professor of psychiatry at the University of California at San Diego.

"People tend to think people with schizophrenia die earlier because of suicide," says Dr. Tony Cohn, a psychiatrist in the schizophrenia and continuing care division at the Centre for Addiction and Mental Health (CAMH) in Toronto. "In fact, 60 per cent of these deaths are from natural causes."

But why are people with schizophrenia so sick?

The first reason is that schizophrenia has psychiatric symptoms that often lead to poor personal habits and can cause individuals to neglect their health. "The illness itself is aligned with lifestyle factors such as lack of exercise," says Meyer. "And the personal motivation to change to healthy behaviour is very, very low. There's also a predisposition to substance abuse. And that, in combination with the separation of physical and mental health care in North America, is very challenging."

Other researchers have found that people with schizophrenia have higher rates of cigarette smoking, higher fat intake and lower fiber intake than the general population. A 1999 study published in Psychological Medicine found that people with schizophrenia exercise less, have higher unemployment and suffer poor health and greater impoverishment due to expenditure on cigarettes.

But while the motivation for positive lifestyle changes may be low, it doesn't mean that people with schizophrenia don't care about their physical health, according to British researcher Dr. David Osborn. In a recent study published in the British Journal of Medicine, Osborn invited people with schizophrenia to visit a doctor for a host of medical tests measuring glucose levels, blood pressure and weight. Osborn invited a comparison group from the general population and had an equal number of voluntary participants from both groups. "The important finding was that as many people with schizophrenia came along as people without," explains Osborn. "The point was to actually illustrate that these people do in fact care about their physical health as much as the rest of us."

Side-effects from medication are another challenge to physical health. Today, people with schizophrenia have access to a new generation of antipsychotic drugs. But while many of these atypical antipsychotics eliminate some of the unpleasant neurological side effects of older medications, they are also related to higher rates of obesity, diabetes, cardiac and other problems.

Weight gain is a particular concern, because it is so common and affects the individual's physical and mental health. A 1999 article in the Journal of Clinical Psychiatry reported that weight gain occurs in up to 50 per cent of individuals taking antipsychotic medication. The weight gain itself can have a negative psychological impact and lead to a loss of self-esteem, which can result in non-compliance with medication, writes Dr. Malcolm Lader in a 1999 article in the same journal.

Dr. Miriam Schuchman, a medical ethics professor at the University of Toronto, notes that individuals taking any of the atypical antipsychotics should have regular blood sugar tests to monitor for diabetes. With a 60 per cent mortality rate due to cardiac problems, people with schizophrenia should also be on the lookout for signs of heart disease, such as a rapid heart rate, shortness of breath or swollen ankles or feet.

Despite recent attention to the side effects of med- ication, Osborn says evidence shows that psychiatrists and family physicians are poor at detecting and treating the physical maladies of psychiatric clients."Most psychiatrists haven't addressed physical health with their clients at all," says Meyer. "The idea is that if you can get clients on a therapeutic medication that treats their mental illness, then they should be left lone. Their other health burdens are secondary. But, if you never talk to people about diet and exercise, you'll have a very low chance of succeeding."

"The classic argument is that people in western society have a difficulty dealing with the fact that physical health and mental health are linked," says Osborn. "If you have a physical health problem, you forget your mental health and vice verse. It's a Descartes-type split between mind and body."

Another problem is that psychiatrists and other mental health care workers are traditionally rarely called upon to practise basic medicine. In his recent book, Issues Surrounding Medical Care for Individuals with Schizophrenia, Meyer suggests that one solution would see dual training of physicians as both certified psychiatrists and primary care physicians. The University of California's San Diego and Davis campuses have already implemented combined training programs.

Dr. Benjamin Druss, the Rosalynn Carter chair in mental health at Emory University in Atlanta, Georgia, has conducted a randomized trial evaluating an integrated model of primary medical care, which had individual case managers and mental and physical health care providers working together under one roof. The results showed that integrated mental and physical health care improved the quality of clients' health and was cost-effective.

Other doctors say that a standardized medical assessment of incoming clients by front-line workers, whether at psychiatric care facilities or in general practice, is an excellent way to screen for medical problems in psychiatric clients. "For example, when somebody comes into a doctor's office, they should have a standardized physical assessment once a year," suggests Osborn. "The client may indicate being particularly worried about cholesterol, lipids, diabetes or cardiac conditions. It would mean a regular schedule of tests and having their weight done, at the very least." (It is worth noting that in Great Britain, the family doctor is usually the main medical contact for people with schizophrenia who live in the community.)

This sort of monitoring is exactly what is happening at CAMH with its Healthy Lifestyle Project for clients with schizophrenia. The project, slated to begin this autumn, links pre-established medical screening protocols with healthy lifestyle intervention. It is based on an integrative treatment approach to clients who have been identified as being either at risk for developing chronic disease or who already have an illness such as diabetes or heart disease.

The new project offers counselling, education and hands-on instruction for clients at risk for various physical health problems, as identified by the screening. Specific components of the project include diabetes education, nutrition counselling and a smoking cessation program, as well as hands-on meal and snack preparation, grocery shopping excursions and promotion of physical activity through recreational therapy. The idea is to increase the ability of clients to make lifestyle changes for healthy living.

A year-long pilot project involving systematic medical screening of clients on antipsychotic medication was also launched at CAMH last winter, and early indications look positive. "We have already picked up a number of undiagnosed diabetics and a lot of undiagnosed lipid problems," says Cohn. "We will also be offering these people diabetes education and lifestyle programming around diet and activity as part of our Healthy Lifestyle Project."

Cohn also runs a weight assessment clinic offering counselling and information about how medications affect weight. The program is very well received and Cohn says clients appreciate the attention given to their physical health.

In short, there is hope. "Good physical health status is a realistic goal in people with mental illness," writes Osborn in the British Journal of Medicine. "This goal should be embraced by all health professionals who provide their care."

 

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