Premature Mortality in Schizophrenia: What Clinicians Can Do

It is now well established that individuals with schizophrenia die, on average, about 15 years earlier than those in the general population.¹ This mortality gap is observed globally, across diverse health care systems. The Figure shows the mean survival time of persons with schizophrenia vs those in the general population based on a meta-analysis of studies from around the world.¹ Despite overall improvements in medical care, the disparity has persisted and may even be widening.

Although suicide and other external causes of death are elevated in schizophrenia, they account for a minority of deaths. Most individuals die from the same chronic medical illnesses that affect the general population, but at younger ages. Understanding why this occurs is essential to closing the gap.

Contributing Factors

Excess mortality in schizophrenia reflects a complex interplay of behavioral, medical, and social factors, many of which are modifiable.

Tobacco smoking remains one of the most significant contributors.² Smoking rates in schizophrenia are substantially higher than in the general population, amplifying risks for cardiovascular and pulmonary disease. Substance use, including alcohol and illicit drugs, further increases morbidity and mortality.

Lifestyle factors also play a critical role. Physical inactivity and obesity are highly prevalent and contribute to cardiometabolic disease.³ The adverse effects of sedentary behavior and elevated body mass index (BMI) are well established in the general population but are magnified in individuals with schizophrenia due to their higher baseline prevalence.

Antipsychotic medications are often implicated in this discussion. These treatments, typically used long term, can contribute to weight gain, metabolic syndrome, type 2 diabetes, and hypertension, as well as sedation.⁴ However, a consistent finding across studies is that adherence to antipsychotic treatment is associated with lower mortality risk.⁵ This apparent paradox likely reflects the benefits of the control of psychiatric symptoms, including improved functioning, better self-care, and greater engagement with medical services.

Cognitive impairment is another important, and often underrecognized, factor. In a prospective study of 844 individuals with schizophrenia followed for up to 24 years, researchers found that lower baseline cognitive performance was independently associated with increased risk of natural-cause mortality.⁶ Moreover, cognitive deficits interacted with other risks such as tobacco smoking, elevated BMI, cardiac arrhythmia, and being divorced or separated, highlighting the cumulative and interrelated nature of these vulnerabilities.

Barriers to Medical Care

Disparities in access to and quality of medical care further contribute to excess mortality. Individuals with schizophrenia are less likely to receive preventive services such as mammography and colonoscopy.⁷ They are also more likely to be diagnosed with serious medical conditions at later stages, when treatment options are more limited.

Even when medical conditions are identified, patients may be less likely to receive indicated procedures.⁸ Contributing factors include fragmented care systems, reduced access, stigma, and challenges related to motivation, cognition, and communication. In some cases, clinicians may inadvertently overlook or underinvestigate physical symptoms.

What Clinicians Can Do

Psychiatrists and other mental health clinicians play a central role in addressing these risks. Several practical strategies can make a meaningful difference.

1. Avoid Diagnostic Overshadowing

Diagnostic overshadowing occurs when physical symptoms are attributed to psychiatric illness rather than appropriately evaluated as potential medical conditions. This bias can delay diagnosis and worsen outcomes. Clinicians should take somatic complaints seriously, pursue appropriate workups, and avoid assuming that symptoms are unavoidable medication adverse effects or manifestations of psychosis.

2. Promote Tobacco Cessation

Tobacco smoking remains among the leading causes of preventable death and is particularly harmful in schizophrenia, given the high prevalence of tobacco use. Encouragingly, smoking cessation treatments have been shown to be safe and effective for this population, without increasing the risk of psychotic relapse.⁹ Evidence-based smoking cessation treatment consists of smoking cessation medication (ie, varenicline, bupropion, or combination nicotine replacement therapy) along with behavioral counseling. Tobacco treatment is increasingly being integrated into routine psychiatric care workflows and can also be championed by individual clinicians.

3. Tailor Communication to Cognitive Needs

Many individuals with schizophrenia experience deficits in memory, attention, and executive functioning. These deficits can impede understanding of health information. Clear, concrete, and repetitive messaging; visual aids; and teach-back techniques may improve comprehension and adherence. Smartphone reminders and other methods of digital communication are also promising strategies.

4. Advocate for Healthy Lifestyles

Supporting regular exercise, balanced nutrition, and weight management should be part of every recovery-oriented treatment plan. Using shared decision-making frameworks can enhance engagement and empower patients to pursue healthier behaviors over the long term. A recent JAMA article suggests that mental health clinicians should provide direct guidance on physical activity tailored to each patient’s preferences and capabilities.¹⁰ The potential benefits of guideline-concordant exercise include improved cognition, reduced psychiatric symptoms, and better cardiometabolic health. Weight management strategies, customized for individuals with schizophrenia and other serious mental illnesses, have also been shown to be effective.¹¹ The new glucagon-like peptide-1 receptor agonist medications are under study in this population and may provide an additional approach to mitigate obesity in this high-risk group.¹²

5. Champion Integrated Care

The separation of mental and physical health systems remains a persistent barrier in US health care. Integrated or colocated care models such as Medicaid-funded health homes have shown promise in improving outcomes. In settings where structural integration is limited, psychiatrists can nonetheless promote coordination by communicating directly with primary care providers, tracking key medical indicators, and encouraging preventive health visits.¹³

Concluding Thoughts

Premature mortality among persons with schizophrenia is multifactorial, but not inevitable. By recognizing modifiable risk factors, avoiding clinical biases, and actively promoting integrated, preventive, and patient-centered care, psychiatrists and other mental health clinicians can play a central role in closing this 15-year mortality gap.

Dr Dickerson is a senior psychologist at Sheppard Pratt in Baltimore, Maryland, a clinical professor in the Department of Psychiatry at the University of Maryland School of Medicine, and an adjunct professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine.

References

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