Folie 1

1
Schizophrenia somatic comorbidity and mortality
W. Wolfgang Fleischhacker Medical University
Innsbruck Austria
2
Summary of physical diseases which occur with
increased frequency in schizophrenia according to
our review

() very good evidence for increased risk (e.g.
population based studies), () good evidence for
increased risk, (-) at least good evidence for
decreased risk. 1 the results on specific forms
of cancer were mostly inconclusive due to
contradictory results and limited power 2 a
side-effect of chlorpromazine, probably not a
problem of most other antipsychotics The table
does not list physical diseases that have only
been shown to be related to the etiology of
schizophrenia (e.g. influenza virus). There were
no clearly increased rates of physical diseases
in the categories parasitic diseases,
digestive system diseases, otorhinolaryngologic
al diseases, eye diseases, hemic and
lymphatic diseases, congenital, hereditary, and
neonatal diseases and abnormalities, immune
system diseases, disorders of environmental
origin, animal diseases, pathological
conditions, signs and symptoms or these diseases
were listed in another category.
S Leucht and N Sartorius 2008
3
Increased Risk Factors for CVD Patients with
Schizophrenia

• ? Risk factors
• ? Obesity (42 BMI 27 vs. 27 in general
  population)
• ? Lipid abnormalities (TC, LDL-C, TG)
• ? Diabetes ( 1.5-2X the general population)
• ? Hypertension
• ? Metabolic syndrome ( 50 vs. 25 in general
  population)
• ? Physical inactivity
• ? Smoking (75 vs. 25 in general population)
• ? Insight
• ? Access to medical care
• ? Utilization of medical care
• ? Compliance with therapies
• ? Economic capabilities

Hennekens CH, et al. Am Heart J. 20051501115-21.
4
(No Transcript)
5
(No Transcript)
6
Kahn et al. Lancet 2008
7
Clinical Consequences of Antipsychotic-Induced
Weight Gain in Patients with Schizophrenia
Health risks hypertension atherosclerosis type
2 diabetes cardiovascular diseases stroke Stigma
tization Noncompliance Impairment of quality of
life Social withdrawal
Kurzthaler et al. J Clin Psychiat 2001
8
(7)
(23)
(17)
(19)
(18)
Kahn et al. Lancet 2008
9
(No Transcript)
10
(No Transcript)
11
Mortality trends in Stockholm County 1976-79 to
1990-95, cardiovascular causes of death
Deaths/100 000
76-79 period of reference
1.4
Patients with schizophrenia
1.2
1
0.8
0.6
General population
0.4
0.2
0
76-79
80-85
86-89
90-95
Controlling for age at first diagnosis and
years of follow-up Standardized by the sex and
age distribution of the patients
Osby et al., BMJ 2000321(7259)483-4.
12
Life Expectancy Patients with Schizophrenia

• Life expectancy 20 shorter than general
  population (61 years vs. 76 years in the general
  population)
• In patients with schizophrenia
• 57 years in men and 65 years in women
• In the general population
• 72 years in men and 80 years in women

Harris EC, Barraclough B. Br J Psych.
199817311-53. Newman SC, Bland RC. Can J Psych.
199136239-245.
13
(No Transcript)
14
Reduced access to services of mentally ill
IHD Hospitalisation Revascularisation Procedure
and Death rates, by Principal Psychiatric
Diagnosis, Western Australia, 1980-1998
(Lawrence and Coghlan N S W Public Health Bull
2002 13(7) 155158)
15
Metabolic adverse events caused by antipsychotics

• weight gain
• glucose intolerance DM II, DKA
• hyperlipidemia cholesterol, triglycerides
• metabolic syndrome

16
Meta-analysis of weight gain liabilities
4 10 week studies, N72
Allison et al., J Clin Psychiatry 2001 62 (suppl
7)22-31
17
Kahn et al. Lancet 2008
18
Proportion of Patients with Elevated Cholesterol
(200 mg/dl)


n182/173 62/62
pFleischhacker WW et al. 2008 Submitted.
19
MetS syndrome in first-episode patients, after 3
year treatment FGA versus SGA
2000 2006 SGA
1984 1995 FGA
De Hert et al. Schiz Res submitted 2008
20
HOMA IR in the course of treatment (clozapine
vs. amisulpride)
a) significant increase from baseline p0-006
Rettenbacher et al. J Psychopharmacol 2007
21
Median change in fasting lipid levels
LDL Cholesterol
Triglycerides
Total Cholesterol



Median change from baseline to endpoint (mg/dL)



Ziprasidone(n113)
Olanzapine(n120)
Ziprasidone(n106)
Olanzapine(n105)
Ziprasidone(n113)
Olanzapine(n120)
Polanzapine. P NS vs baseline.
Simpson et al. Am J Psychiatry 2005
22
Canadian journal of psychiatry, 2006
23
Belgian Guidelines

• Before start SGA evaluate all metabolic risk
  factors of the patient
• Choice between SGA with equal efficacy consider
• The metabolic risk of the product
• The present metabolic risk factors of the patient
• SGA with a low metabolic risk is to be preferred

De Nayer et al. 2005
24
Belgian Guidelines

• Close follow-up and monitoring for metabolic
  abnormalities (pre-diabetes, diabetes, obesity,
  metabolic syndrome, dyslipidaemia)
• If present/emerging
• Consider switch to SGA with lower metabolic risk
• Treat abnormalities
• Inform patients and carers adequately
• Set up good collaboration with GP and if needed
  with diabetologist

De Nayer et al. 2005
25
Comprehensive Clinical Monitoring Physical Care
Citrome and Yeomans. J Psychopharmacol.
200519102109
26
Fleischhacker et al. JCP 2008
27
, Fleischhacker et al. JCP 2008, J Clin Psychiat
200869 514-519
28
Conclusions

• Physical wellbeing of people with psychiatric
  disorders should be on a par with the general
  population.
• People with SMI have limited access to physical
  health care.
• Educational efforts for all clinicians are
  needed.
• Primary prevention in patients with SMI are even
  more crucial than in the general population.
• Management strategies such as medication
  switching or adjunctive medications, have
  demonstrated benefits in patients with a present
  or emerging risk.

Fleischhacker et al. JCP 2008