Friday 19 October 2012

The health inequalities of schizophrenia

Heart to heart @ Wikipedia  
Dare I start this post by saying that when it comes to many conditions with a behavioural or cognitive aspect to them, there are some worrying trends emerging from the research literature suggestive of stark differences in both access to healthcare and indeed mortality statistics compared with the general population. Think wandering and elopement with autism in mind as one prime risk factor.

I've touched upon health inequality before with autism spectrum disorders in mind, but on this occasion want to briefly discuss some of the literature with schizophrenia spectrum disorders in mind following yet another revelation of more overlap between the conditions.

The paper which brought me to this post is this one from Paul Kurdyak and colleagues* who reported that people diagnosed with schizophrenia were more likely to die as a result of an acute myocardial infarction (heart attack to you and me) and indeed were less likely to receive the appropriate care (including access to a specialist physician) after such an event. 

The quite shocking figures: individuals with schizophrenia were 56% more likely to die within 30 days of discharge and 50% less likely to receive the appropriate after-event healthcare. One could argue on this basis that schizophrenia and its effects go well beyond the psychiatric symptoms that characterise the condition.

Of course there is already quite a lot of suggestion that schizophrenia and related conditions might place an individual at higher risk of quite a few different conditions. So for example, diabetes - type 2 diabetes - is something which has been on the research radar for a while now as per the study by Schoepf and colleagues**. So too issues with obesity, being overweight and other parts of the so-called metabolic syndrome as per reports like the one from Subashini et al*** covering some of the more usual suspects with heart health risk in mind.

The hows and whys of such an increased prevalence of such conditions are complicated. Certainly the research literature seems to suggest that just having a schizophrenia spectrum disorder might increase the risk of engaging in known lifestyle choices linked to poorer heart health. So smoking tobacco, including being heavy tobacco smokers, seems to be more frequent in cases of schizophrenia as per this study by Zhang and colleagues**** (open-access). Physical inactivity has also been reported to be more common too***** and perhaps even tied into illness duration. Not to also mention a role for food choices****** albeit not necessarily consistently*******. There is however some difficulty in unpicking individual behaviours and factors when assessing overall risk.

Before anyone suggests that I am somehow apportioning 'blame' in listing these lifestyle choices, I think it is also important to highlight other factors as potentially contributing to a heighten risk including that of pharmacotherapy. By saying this I'm not going down the 'pharma-bashing' route despite some quite worrying issues recently discussed reiterating that medicines tend to have quite a few more actions that those just indicated on the insert. No, but certainly some of the medicines used to manage schizophrenia and other conditions have long been linked to certain cardiometabolic issues as per editorials like this one from Remington********. Indeed I have a post scheduled soon talking about antipsychotics and autism following the recent NICE guidance published on adult autism which will discuss this further. Good medicines management seems to be key to mitigating the effects of such risks.

Social factors might also play an important role in the accessing of appropriate healthcare for conditions like schizophrenia. Here in the UK we have something called the NHS (National Health Service) which provides healthcare to everyone "free at the point of use". Not everywhere in the world has such a generous policy however as studies like this one by Khaykin and colleagues********* which suggested that around 7% of their cohort with schizophrenia were medically uninsured all year round.

Although perhaps mixing apples and oranges, when you take into account the high rates of unemployment associated with a diagnosis of schizophrenia, upto 96% according to this study by Perkins & Rinaldi**********, having the financial means to access healthcare in some parts of the world must surely be considered an important factor in determining outcome.

I don't claim to have covered all the literature on health inequality and schizophrenia in this post. Indeed the reasons for the figures cited by Kurdyak are likely to be complex and multiple across different people and different situations. What perhaps such data do suggest however is that looking beyond the immediate and overt presentation of mental 'ill-health' should be a priority where general healthcare is concerned. Realising for example, that ticking boxes on a clinical diagnostic schedule and managing current symptoms of that condition might do little for the long-term health of that individual. Indeed when faced with a life expectancy potentially reduced by the order of 14 years*********** there is most definitely a real issue to be tackled here.

To finish a song about blackbirds by the Beatles.


* Kurdyak P. et al. High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia. Schizophr Res. September 2012.

** Schoepf D. et al. Type-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up. Eur Psychiatry. 2012; 27: 33-42.

*** Subashini R. et al. Prevalence of diabetes, obesity, and metabolic syndrome in subjects with and without schizophrenia (CURES-104). J Postgrad Med. 2011; 57: 272-277.

**** Zhang XY. et al. Cigarette smoking in male patients with chronic schizophrenia in a Chinese population: prevalence and relationship to clinical phenotypes. PLoS One. 2012; 7: e30937.

***** Vancampfort D. et al. A systematic review of correlates of physical activity in patients with schizophrenia. Acta Psychiatr Scand. 2012; 125: 352-362.

****** McCreadie RG. et al. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry. 2003; 183: 534-539.

******* Henderson DC. et al. Dietary intake profile of patients with schizophrenia. Ann Clin Psychiatry. 2006; 18: 99-105.

******** Remington G. Schizophrenia, antipsychotics, and the metabolic Syndrome: is there a silver lining? Am J Psychiatry. 2006; 163: 1132-1134.

********* Khaykin E. et al. Health insurance coverage among persons with schizophrenia in the United States. Psychiatr Serv. 2010; 61: 830-834.

********** Perkins R. & Rinaldi M. Unemployment rates among patients with long-term mental health problems. The Psychiatrist. 2002; 26: 295-298.

*********** Chang CK. et al. Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One. 2011; 6: e19590

---------- Kurdyak P, Vigod S, Calzavara A, & Wodchis WP (2012). High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia. Schizophrenia research PMID: 23021899

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