Reducing morbidity and mortality from common medical conditions in schizophrenia

Management for dyslipidemia.

• Educate the patient and family about risks involved with dyslipidemia.
• Monitor weight and BMI at each visit.
• Monitor lipids to rule out dyslipidemia. Obtain a pretreatment fasting or random lipid profile for any patient receiving an antipsychotic; repeat at least every 6 months after starting the antipsychotic.
• Counsel the patient to quit smoking.
• Switch to an antipsychotic with lower risk of weight gain and dyslipidemia, such as switching from olanzapine or high-dose quetiapine to high- or medium-potency typical antipsychotics (such as, haloperidol or perphenazine), ziprasidone, aripiprazole, iloperidone, and lurasidone (Table 2).
• Educate and encourage the patient about modest physical activity. For example, a 20-minute walk everyday will reduce cardiovascular disease risk by 35% to 55%.⁶
• Refer to a dietitian if indicated.
• Ensure follow-up and initiation of treatment with a general practitioner.
• Educate and encourage the patient about modest physical activity. For example, a 20-minute walk everyday will reduce cardiovascular disease risk by 35% to 55%.

Metabolic syndrome
Metabolic syndrome is cluster of cardiovascular risk factors, including central adiposity, hyperglycemia, dyslipidemia, and hypertension. The National Cholesterol Education Program’s Adult Treatment Panel III report defines metabolic syndrome as the presence of 3 of 5 of the following factors:

• abdominal obesity (waist circumference of >40 inches in men, or >35 inches in women)
• triglyceride level, >150 mg/dL
• HDL cholesterol, <40 mg/dL in men and <50 mg/dL in women
• blood pressure, >130/85 mm Hg
• fasting plasma glucose level, >110 mg/dL.

The presence of metabolic syndrome in the general population is a strong predictor of cardiovascular diseases and diabetes.¹⁸ The adverse effects of metabolic syndrome are thought to relate to atherogenic dyslipidemia, higher blood pressure, insulin resistance with or without glucose intolerance, a proinflammatory state, and a prothrombotic state.

The prevalence of metabolic syndrome in patients with schizophrenia is 2- to 3-fold higher than the general population.¹⁹ In the CATIE study, approximately one-third of patients met criteria for metabolic syndrome at baseline.¹⁵ In a prospective study, De Hert et al²⁰ reported that patients who were started on a SGA had more than twice the rate of developing metabolic syndrome compared with those treated with a FGA (Table 2). Other possible causes of metabolic syndrome are visceral adiposity and insulin resistance.¹⁶Management of the metabolic syndrome involves addressing the individual components that have been described in the preceding sections on T2DM and dyslipidemia.

Hepatitis C
Hepatitis C virus (HCV) infection is thought to be the most common blood-borne illness, with an estimated prevalence of 1% of the U.S. population. Some studies suggest that as many as 16% of people with schizophrenia have HCV infection.⁴ Risk factors for HCV infection include unsafe sexual practices, prostitution, homosexuality, homelessness, and IV drug use.

HCV treatments typically have involved regimens with interferon alfa, which is associated with significant neuropsychiatric side effects, including depression and suicide. There is a dearth of research on treatment of HCV in patients with schizophrenia; however, at least 1 study suggests that there was no increase in psychiatric symptoms in patients treated with interferon-containing regimens.²¹ There is even less evidence to guide the use of newer, non-interferon–based HCV treatment regimens that are better tolerated and have a higher response rate in the general population; there is reason, however, to be hopeful about their potential in patients with schizophrenia and HCV infection.

Managing HCV infection.

• Educate the patients and family about risk factors associated with contracting HCV.
• Screen for HCV infection in patients with schizophrenia because there is higher prevalence of HCV in these patients compared with the general population.
• When HCV infection is diagnosed, educate the patients and family about available treatments.
• Facilitate referral to an HCV specialist for appropriate treatment.

HIV/AIDS
HIV infection is highly prevalent among people suffering from severe mental illness such as schizophrenia. The incidence of HIV/AIDS in patients with schizophrenia is estimated to be 4% to 23%, compared with 0.6% in the general population.²² Risk factors associated with a higher incidence of HIV/AIDS in patients with schizophrenia are lack of knowledge about contracting HIV, unsafe sexual practices, prostitution, homosexuality, homelessness, and IV drug use.²²

Managing HIV/AIDS.

• Educate the patient and family about risk factors associated with contracting HIV/AIDS.
• Educate patients about safe sex practices.
• All patients with schizophrenia should be screened for HIV because there is 10-fold higher HIV prevalence in schizophrenia compared with the general population.
• When HIV infection is diagnosed, facilitate referral to a HIV or infectious disease specialist for treatment.
• Educate the patient in whom HIV/AIDS has been diagnosed about the importance of (1) adherence to his (her) HIV medication regimen and (2) follow-up visits with an infectious disease practitioner and appropriate laboratory tests.
• Educate the patient’s family and significant other about the illness.
• Screen for and treat substance use.
• At each visit, inquire about the patient’s adherence to HIV medical therapy, viral load, and CD4 cell count.