General Medical Concerns
The average patient with schizophrenia lives 16 years less than others in the general population, Nasrallah noted, and the reasons are many.
Cardiovascular disease is the leading cause of premature death in patients with schizophrenia, according to Nasrallah.
"Generally, our patients have terrible lifestyles. They are sedentary, and they don't exercise. They have a poor diet, high in saturated fat. In addition, some of the medications prescribed for them [e.g., antipsychotics, mood stabilizers and antidepressants] can increase their appetite. And gaining weight can be a very serious pathway to multiple medical problems, such as type 2 diabetes, hyperlipidemia, hypertension, sleep apnea and ultimately heart disease and stroke."
Additionally, 70% to 80% of patients with schizophrenia are chronic heavy smokers, he said. "A lot may die because of emphysema, asthma or obstructive lung disease," he added.
Another complicating factor is that many patients with schizophrenia often have reduced pain perception. The literature is full of reports of how patients with schizophrenia who have a ruptured ulcer, chest pain indicative of a heart attack, cigarette burns on the skin or severe abdominal pain tend not to feel the pain as much as others do, Nasrallah said (Nasrallah, 2005b; Torrey, 2002). A neurochemical deficit may cause their lack of response to pain cues, but the result is that many patients with schizophrenia may not seek medical help when they need it. Individuals with chronic psychosis are also highly susceptible to infections such as HIV and hepatitis due to their frequent substance abuse.
Many patients with schizophrenia, Nasrallah added, also have comorbid neurological conditions, such as epilepsy and movement disorders, as well as hard and soft neurological signs.
"Some may have strokes, of course, because of the weight gain and development of metabolic syndrome. Having said that, I need to add that not all the metabolic disorders, like diabetes, are induced by gaining weight. There is evidence that even at the beginning of the illness, before they are ever treated, patients with schizophrenia have a tendency to develop diabetes or are already diabetic, about twice as many as the general population. We don't understand why there is a higher rate of diabetes at the onset of the illness," he said. "What we know is that over time, as we treat them and as they gain more weight (although certain medications can induce sudden diabetic ketoacidosis without weight gain), the rate of diabetes can go up to four of five times that of the general population."
Of great concern to Nasrallah is the under-diagnosis and under-treatment of neurological and medical conditions among patients with schizophrenia. At the recent American College of Neuropsychopharmacology meeting in Waikoloa, Hawaii, Nasrallah presented data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study.
At the time that 1,460 patients with schizophrenia entered the CATIE study, the majority of those who had diabetes were not receiving treatment for their medical condition, the majority of those who had hypertension were not receiving treatment and the majority of those who had high cholesterol and high triglycerides were not receiving treatment, Nasrallah said (Nasrallah, 2005a).
"Society is not providing schizophrenia patients with the standard health screening and treatments available to most people in the United States. Individuals with schizophrenia go through life receiving very little medical attention. So not only do patients with schizophrenia neglect themselves when they are medically ill, but the system does not provide them with adequate medical care," he said. "It is a case of double jeopardy."
There are community mental health centers, he said, where patients with schizophrenia can refill their psychiatric medications, but there is no coordinated system of primary care clinics for patients with schizophrenia. They don't have a primary care physician to treat them and intervene when necessary. "That kind of system neglect for a disabled population, I believe, is inexcusable," Nasrallah said.
Only the U.S. Department of Veterans Affairs system of hospitals and clinics takes care of patients with schizophrenia properly, both medically and psychiatrically, according to Nasrallah.
"I think the VA is doing a great job in mandating that every psychiatrically ill patient ... should also have a primary care physician or nurse practitioner who follows them up regularly, and patients must have an annual physical exam documented in the chart," he added.
One of the major findings of the CATIE study was three-quarters (74%) of patients with schizophrenia stopped taking their antipsychotic medication within 18 months (Lieberman et al., 2005). Nasrallah described it as "dismal adherence that reflects the lack of pharmacotherapy effectiveness in the real world."
"We have medications that work and can actually stabilize the illness, at least many of the symptoms, but we are not reaping the benefits of those medications due to the poor adherence and premature discontinuation," Nasrallah said. "The discontinuation is probably part of the disease. Schizophrenia is a brain disease. Many patients do not believe they are sick. They are not aware of their illness. And they don't feel that they need the medication, especially after they improve a little bit. ... Also, part of schizophrenia involves negative symptoms—apathy and amotivation—toward doing anything, and that includes taking pills and taking care of yourself health wise. ... There is also paranoia, which is part of the illness. It makes some patients stop their medications, because they think they are poisoned and that somebody is trying to harm them with the medication. This noncompliance gets particularly intense when they suffer side effects. Even the slightest side effect may make the patient avoid these medicines."
If all the above reasons were not enough, Nasrallah added that 50% to 60% of patients with schizophrenia who are living in the community are abusing drugs (e.g., alcohol(Drug information on alcohol), marijuana, cocaine, heroin and methamphetamine). Such drugs destroy their ability to think, plan and reason, all of which are necessary for adherence to occur.
The primary principle in treating patients with schizophrenia is to develop a very good therapeutic alliance with them.
"Basically, the patient and the doctor then become partners in fighting the illness," Nasrallah said. "We don't just give pills. We need to engage the patients and make them part of the therapeutic alliance with us ... That trust becomes a foundation to build an adherence schedule on."
Making it simpler for patients to take the antipsychotic medications also can build adherence. Nasrallah advocates giving patients antipsychotics once a day, at bedtime. Nasrallah also believes the increased use of injectable medications can build adherence.
"We have long-acting medications that we can give intramuscularly once every two or four weeks, and more are being developed as we speak," he said. "So many patients who clearly cannot adhere should be considered as candidates for intramuscular injections. ... I have followed up patients who have taken long-acting atypical antipsychotics, a shot every two weeks, for four or five years, and they have done outstandingly [well]. They stopped relapsing, gradually regained a lot of their insight and judgment and were able to go back to work or school.
"I think there is an opportunity for the brain to recover, gradually and surely, and there is evidence that some brain tissue is actually restored gradually over time with the medications that we are using right now. Neuroplasticity, neuroprotection and neurogenesis can be induced and enhanced, and that may be the promise of the future," Nasrallah added. "If we can make sure the patients are consistently taking their medications, we may see recovery and total remissions that currently are not encountered very often."