Chronic obstructive pulmonary disease
Patients with schizophrenia are more likely to suffer from respiratory disease, such as chronic obstructive pulmonary disease (COPD) and asthma, compared with the general population.23 Smoking is a major risk factor for COPD. In a study by Dickerson et al,24 64% of people with schizophrenia were current smokers, compared with 19% of those without mental illness.
A high rate of smoking rate among people with schizophrenia suggests a “self-medication” hypothesis: That is, stimulation of CNS nicotinic cholinergic receptors treats the negative symptoms of schizophrenia and overcomes the dopamine blocking effects of antipsychotics.25 Among SGAs, only clozapine has a substantial body of evidence to support its association with decreased smoking behavior.
Managing COPD.
- Educate the patient and family about risk factors associated with COPD and smoking.
- Screen for tobacco use at each visit; try to increase motivation to quit smoking.
- Educate the patients and family about the value and availability of smoking cessation programs.
- Prescribe medication to help with smoking cessation when needed. Bupropion and varenicline have been shown to be effective in patients with schizophrenia; nicotine replacement therapies are safe and can be helpful.
- When treating a patient who is in the process of quitting, encourage and help him to maintain his commitment and enlist support from his family.
- Refer to an appropriate medical provider (primary care provider or pulmonologist) for a patient with an established or suspected diagnosis of COPD.
Cancer
Since 1909, when the Board of Control of the Commissioners in Lunacy for England and Wales noted the possibility of a decreased incidence in cancer among psychiatric patients, this connection has been a matter of controversy.26 Subsequent research has been equivocal; the prevalence of cancer has been reported to be either increased, similar, or decreased compared with the general population.26-28 Risk factors for cancer, including smoking, obesity, poor diet, sedentary lifestyle, and hyperprolactinemia, are more common among patients with schizophrenia.
Genetic factors and a possible protective effect from antipsychotics have been cited as potential causes of decreased prevalence. Clozapine is associated with an increased risk of leukemia. No conclusion can be drawn about the overall prevalence of cancer in schizophrenia.
Managing cancer in a patient with schizophrenia, however, poses a significant challenge29; he might lack capacity to make decisions about cancer treatment. The patient—or his surrogate decision-makers—need to carefully weigh current quality of life against potential benefits of treatment and risks of side effects. Adherence to complex, often toxic, therapies can be challenging for the patient with psychosis. Successful cancer treatment often requires close collaboration between the cancer treatment team and the patient’s support system, including the treating psychiatrist and case management teams.
Bottom Line
Patients with schizophrenia are at higher risk of developing comorbid medical
conditions because of the illness itself, lifestyle behaviors, genetics, and adverse
effects of medications. Because mental health clinicians focus attention on the
psychiatric and behavioral aspect of treatment, often there is delay in screening,
detecting, and treating medical comorbidities. This screening can be done in any
psychiatric practice, which can lead to timely management for those conditions
and preventing premature mortality in patients with schizophrenia.