Physical health monitoring for people with schizophrenia

I think this idea of first causing no harm is not a bad thought for medicine, right? and I need to treat in the short-term with the view to the long-term.

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When we consider the health needs of people with schizophrenia, sometimes the physical, preventative health monitoring can be down-prioritised compared to other really important clinical concerns. And yet, much of the early mortality of people who live with schizophrenia can be attributed to potent and modifiable risk factors like obesity, smoking, and type 2 diabetes. Today, on the Australian Prescriber Podcast, we're going to discuss the physical health risk factors for people with schizophrenia and what enhanced physical health monitoring, as part of a multidisciplinary holistic approach, would ideally look like.

I'm Dr Laura Beaton. I'm your GP host for this episode. And I'm joined by Professor David Castle, a professor of psychiatry at the University of Tasmania, who has a longstanding interest and research body of work in the area of physical health for people with severe mental illness. He's written about this topic along with his co-author, Amy Li, for Australian Prescriber. David, thank you so much for being with me today.

Thanks so much for having me.

So it is a little bit of a sombre start to the episode today. Despite all the advances in the treatment options for people with schizophrenia, why is there still such a reduced life expectancy for these patients?

That is a very, very good question and very complex, actually. So what we do know is that most of the shortening of lifespan for people with severe mental illness is due to cardiovascular risk factors. Some of the genes which code for schizophrenia also code for other medical disorders like diabetes, for example. So there's that risk factor, but more importantly are the lifestyle risk factors. Cigarette smoking is a very important and big one.

There's also high rates of untreated hypertriglyceridaemia, hypercholesterolaemia, diabetes, obesity, and so forth. And we know that people with these disorders don't get the same level of care and the same level of interventions that are afforded the general population. The other thing is that some of the medications which we use in psychiatry add to the burden. Certain antipsychotic medications are very strongly associated with weight gain, emergent diabetes, and so forth.

Thanks, David, for that overview. Why are these patients sometimes not offered the same level of preventative health care that other patients may be around modifying their cardiometabolic risk?

This is a key issue and, again, a complicated answer because part of it undoubtedly has to do with stigma associated with people with severe mental illness. In surveys which we've done, they do access GPs, but I think that the consultations are overshadowed with a discussion about psychotic symptoms rather than about metabolic and other lifestyle issues. And that's not just the case for GPs, by the way. I think in psychiatry we're probably even worse at that because we think, if we've ameliorated the distress of the person's auditory hallucinations and their delusions that we're doing a good job. Well, yes we are, but there are all sorts of other issues which we are maybe not addressing.

The other thing is patient empowerment, educating them, telling them about the risk factors, trying to motivate them to deal with the risk factors, I think these are key. And we have an exciting opportunity now. In fact, we just have a large study about to kick off which is looking at using peer workers, so those people with lived experience, to try and motivate people with mental health problems to engage in better physical activities, to enhance their physical health, try and address their smoking, and so forth and so on. And we think using peers might break down some of the barriers. People might be more likely to listen to somebody who's been through the same issues that they have been through.

And we, also, on top of that, are putting in what has been called nurse navigators. Doesn't have to be a nurse. It's just a term which we tend to use. It's someone to actually guide the person through the health system, which, of course, is pretty complicated.

I think also there is an issue with regard to general practice now. Back in my youth, that everybody had a general practice, the general practitioner who knew the patient and knew the family and usually delivered the patient, and there was that great longitudinal relationship with GPs. Unfortunately, in a lot of practices, that has broken down and patients decry the fact that they see a different GP every time they attend. So there we really need to be smart about using technology to make sure that the communication is happening so every person they see, there might be a different person, but the information about what has been done and what hasn't been done and what is due to be done is carried with them.

One of the most potent modifiable risk factors you mentioned was smoking. What's been your experience with smoking cessation for these patients?

The first thing about smoking is not to just accept, oh well, they smoke and they're never going to change, because that's not true. People with schizophrenia and related disorders have often tried [to quit smoking] but have very commonly relapsed. Now, why is a story which is again very complicated and has to do with underlying reward mechanisms in the brain and so forth, but also [nicotine] is a cognitive enhancer and everything else which goes with smoking. So this is very strongly inured in people's lives and to really help them, we need to keep on asking and telling them that they can get the help.

The Quitline story is interesting. So, again, very, very good work happens with the Quitlines, but what we have found generally is that the usual Quitline staff are not necessarily that skilled when it comes to dealing with people with severe mental illness. So we have done some projects along with colleagues up in Newcastle around enhanced Quitlines where people would be encouraged to phone the Quitline for smoking cessation and the person at the other end would be someone who had extra specific training around mental health. That's something which Quitline of Victoria at least embraced and seems really, really helpful. The other thing is, yes, using smoking cessation, pharmacologically solid, evidence-based treatments is something we should be doing and should be offering. NRT [nicotine replacement therapy] is probably still the easiest and safest, but a lot of people with schizophrenia are very, very heavy smokers and find NRT just doesn't work for them or needs to be used in a number of different forms. So often people would have patches plus gum plus lozenges, and I think there we need to step outside our own little comfort zone a bit as prescribers and be aware that sometimes we need to go above what would be usual practice in terms of NRT.

And then there are a number of other medications, as you know, pharmacological approaches. There's a noradrenaline dopamine reuptake inhibitor called bupropion. The problem with it is it can perturb mood, especially in people with bipolar disorder or schizoaffective disorder. It's not to say it's a no-no, but you've got to be aware of that. And, of course, varenicline is the most effective of all of these in terms of pharmacological interventions and is underused. And it's underused because we have been made aware of potential neuropsychiatric problems associated with its use. But if you look at those data in detail, actually that risk is probably overstated. And there's 2 sources of information around that. One is the EAGLES study, which I'm sure most of your listeners would be aware of, which showed not only was varenicline the most potent of the agents which were looked at, which was bupropion, NRT, or varenicline, but also was actually pretty well tolerated even in people who did have a mental illness.

Although, there's criticisms of the EAGLES study in terms of the small number of people (even though it's a massive study, a small number of people had psychotic disorders within it), but we ourselves have done work with varenicline and shown it to be effective and safe. And there's large studies from the US, Jill Williams and others, who have shown it to be useful. So, certainly underused, and it's not to say you go around using it lightly. You prepare the patient, you make clear what the side effects may be, and some of those side effects can be dangerous, like increases in suicidality. So what we tend to do is to make sure the patient's aware, bring a family member in and have a discussion with them around that, and also make regular phone calls to just check up how people are going and then regular appointments to review them.

And so let's say we do manage to work with someone to reduce and quit smoking. There are some dose adjustments for certain antipsychotic medications that's actually important if they do entirely stop smoking. What are those?

Yeah, so smoking has implications for the metabolism of certain drugs, which we need to have precautions about. The most important one is clozapine. Clozapine is a very particular antipsychotic which is used for treatment-resistant patients. Interestingly, actually, clozapine seems maybe to reduce the drive to smoke and use other substances as well, which is intriguing. So clozapine, you need to be aware because if you stop smoking, your levels can go up and you can become toxic. The magic number seems to be 7, that once you are below 7 cigarettes a day, that's when it starts having implications for clozapine levels. There are other drugs as well, antipsychotics, like olanzapine, but probably not as severe an issue because they're not as dangerous in terms of toxicity.

So we started talking in this episode about cardiovascular and metabolic risk, and so it won't be surprising that type 2 diabetes, hypertension, and dyslipidaemia are commonly comorbid with schizophrenia. David, what are the disease or treatment-specific aspects of these conditions that GPs are likely contending with?

It's been shown that people with schizophrenia who also have diabetes are extremely adept at dealing with their diabetes if they're given the right support and if they're given the right instruction. And that can make a massive difference to their lives. So, again, it's a matter of empowering them. Some people with schizophrenia, of course, do unfortunately have ongoing psychotic symptoms, disorganisation symptoms, and also have a problem with access to health care. So there I think extra support, extra education, and also bringing in family members or, again, the use of a peer worker would be a really good opportunity, and don't deny people the care which we would give to everybody else. So everybody else would get access to dietitian advice and you'd get advice from a diabetes educator. There's no reason why our patients with schizophrenia shouldn't be afforded the same level of care. Sometimes the information needs to be done in a slightly different way, but that's better than no information at all.

And the risk factors for these metabolic syndromes actually overlap with the risk factors for obstructive sleep apnoea [OSA]. And OSA gets a special mention in your article. Can you talk about OSA and schizophrenia and how actually some symptoms can be misattributed to schizophrenia?

Sleep and sleep disturbances are very common amongst people with schizophrenia, but sleep apnoea is one which is often missed because a lot of people with schizophrenia don't have a sleeping partner. So that's one factor, just under-reporting. The other thing is that, of course, we often add into the mix of things very sedating medications, and that can exacerbate sleep apnoea. So, again, it's a matter of taking the history, not assuming that everything you see is due to schizophrenia. You would say, "Oh well, they're very tired during the day. Well, that's because they've got schizophrenia." Well, it's not. It might be because they've got sleep apnoea or various other physical health problems. So awareness, asking, trying to get a collateral if that's appropriate, but also getting the opportunity for people to have proper testing.

And I think it's somewhat easier now with some of the devices which you can actually wear at home rather than having to go in and do a full sleep study in a lab. And that might be less intimidating, might not be quite as accurate, but it's certainly better than nothing. And then there's an issue because a lot of people with schizophrenia in my experience, don't particularly want CPAP [continuous positive airway pressure]. Now, CPAP, obviously, can be extremely helpful for severe sleep apnoea. But it is awkward. So the opportunity for the person to really talk through the pros and the cons of the different options like jaw splints and so forth, as well as CPAP as being an option and what the pluses and minuses are, I think that that should be afforded them the opportunity to have that discussion.

And let's move on now to maybe the most commonly known adverse effect of antipsychotic medications, hyperprolactinaemia. Can you do a little mini-refresher for our listeners on which drugs are the biggest culprits, and the symptoms we should look out for because some patients may not want to bring up these symptoms with us.

So you're alluding to the sexual side effects, which are often sensitive and are not asked about because we get shy about it or we don't ask about it in the right way. And people don't tend to volunteer about sexual side effects in particular. There's also potential for gynaecomastia, for galactorrhoea. I remember having a young woman who had a belief that she was possessed in some way, started on a very low dose of an antipsychotic, and she came back and I said, "How are things going?" And she said, "Well, now I know I'm a witch." And I said, "What do you mean?" And she had started lactating and then she interpreted that in a delusional way.

And the other thing which is not seen, i.e. not seen through the eyes, is bone mineral density. So with ongoing hyperprolactinaemia, you get an increase in bone mineral turnover, osteopenia. And if you think about it, a lot of people with schizophrenia already have risk factors for fractures because of not a lot of high impact exercise to strengthen their bones, maybe not the best diets, not a lot of calcium, hypervitaminosis D, all these things. Then add in hyperprolactinaemia and you really have an issue with bone health. So being aware of this and being aware of certain antipsychotics, in the older drugs like haloperidol and droperidol, ‘second-generation’ drugs like risperidone, amisulpride, almost uniformly raise prolactin.

So being aware, monitoring, and there are options. There are other drugs which don't raise your prolactin. So maybe that would be a better way to go. I think this idea of first causing no harm is not a bad thought for medicine, right? So the idea there is, if you have a drug which is going to be causing hyperprolactinaemia, is there an option which is not going to cause hyperprolactinaemia? If there's a drug which is going to cause diabetes or exacerbate diabetes and weight gain, are there alternatives? And if the alternative is available, why don't you use those?

My other thing here is that you treat in the short-term with the view to a long-term. So schizophrenia is a long-term problem for a lot of people and need ongoing medications quite often. That is forgotten and you start with an easy medication to use, but it's a high metabolic-burden medication or a high prolactin-burden medication because it's easy, and then you just carry on with it and the person becomes physically really unwell because of what you have done because you didn't think I need to first do no harm and I need to treat in the short-term with the view to the long-term.

Thank you for mentioning some of these long-term and more invisible health risks like osteoporosis, and it sounds like it's another good case as well as thinking about when we use these fracture risk calculators or cardiovascular risk calculators. In fact, people with schizophrenia may be in a higher risk category than may come out on a standard fracture-risk metric that we might be using day-to-day. And so, finishing up the article, you actually provide some really helpful monitoring parameters and time periods, and we GPs are really well placed, not just to monitor the physical health, but also work alongside patients and other members of the care team on these modifiable risk factors. And so I'd really like to encourage our listeners to read the full article, which is freely available on the Australian Prescriber website, and also bookmark those summary tables for use when you are doing regular chronic disease management plans and reviews with your patients with schizophrenia. David, thank you for this article and taking the time to talk about it on the Australian Prescriber Podcast.

It's a pleasure. Thank you so much.

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The views of the host and the guests on this podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. David Castle has received grants for research on schizophrenia and antipsychotics from the National Health and Medical Research Council, Medical Research Future Fund, Barbara Dicker Foundation, Canadian Institute for Health Information, Brain Canada, Servier, and Boehringer Ingelheim. He has also received travel support and honoraria for presentations and consultancy from Servier, Seqirus, Lundbeck, Mindcafe, Psychscene, and Inside Practice. He was a co-author of the Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the Management of Schizophrenia and Other Related Disorders (2016), and an author on Being Equally Well (2021). He founded the Optimal Health Program and holds 50% of its intellectual property, and is part owner (5%) of Clarity Healthcare.