Weighing up the importance of physical health in schizophrenia

In the aftermath of a first-episode of psychosis and following a schizophrenia diagnosis, attention rightly falls on preventing relapse. Managing and preventing acute psychotic episodes is a mental health priority and an on-going management goal for any young person given a diagnosis of schizophrenia. Care aims to allow young people with psychosis to have as near normal expectations of life as their peers.

Yet we know that such young people face a reduced life-expectancy, in large part linked with their disproportionately higher risk for cardio-metabolic disease.¹ We also know that the physical health gap between people with schizophrenia and the general population persists despite general trends for reduced cardiovascular mortality in recent years.²

So much to lose

Much of the problem is linked with weight gain – which in case we forget – is in itself often linked with significant psychological effects. Like everyone else, people experiencing psychosis have concerns about weight gain, weight management and body image.

Rapid weight gain in young people with newly diagnosed schizophrenia is a common phenomenon that increases cardio-metabolic risk profile and contributes to risk of premature death.³ The use of antipsychotic treatments has been linked with this rapid weight gain and poses an on-going conundrum for prescribers – how to balance the mental and physical long-term health risks faced by patients.

Risks rise in less than 2 years

This issue has once again come to prominence following publication of a recent meta-analysis looking at the impact of antipsychotic use in young people.⁴ Longitudinal studies with a mean follow-up of 1.7 years suggest that although overt type 2 diabetes in young patients is quite rare, antipsychotic use does increase the risk of developing diabetes when compared with risks in both healthy controls and psychiatric controls.⁴

Given the known risks, it has been suggested that people receiving antipsychotics for schizophrenia might benefit from active therapeutic management of cardio-metabolic risks.⁵

Not inevitable - preventable

But there are other schools of thought that play better to the concepts of early intervention and early patient support, and which take a more preventive approach to the physical health issues that may face young people with a new diagnosis of schizophrenia. Such approaches are based on the belief that weight gain and elevated cardiovascular risks are not inevitable, and on evidence that lifestyle intervention to support good physical health can prevent the seeding of future disease risk.⁶

Also of interest is that the recent meta-analysis of antipsychotic use and increased diabetes risk has flagged once again that not all antipsychotic agents have the same cardio-metabolic effects^3,4. This is pertinent when making initial treatment choices in young patients embarking on chronic therapy for psychosis.

Don’t just screen - intervene

Weight gain and obesity are modifiable risk factors and it is not just severe weight gain that needs to be tackled.⁷ Indeed the longer a person is overweight, the harder it becomes to lose that weight.

A number of initiatives in recent years have shown that in young people with newly diagnosed schizophrenia it is feasible and practical to intervene and support patients before obesity and its ensuing metabolic risks become entrenched.

Weight gain and elevated cardio-metabolic risks are not inevitable

Healthcare teams in New South Wales Australia are among those spearheading concerted programmes designed to support young people with schizophrenia in achieving good physical health.^1,6,8 Speaking at the American Psychiatry Association (APA) meeting in 2015*, endocrinologist Professor Samaras from this Australian group said that a weight gain of >7% from initial body weight is considered a level at which metabolic risks increase. This means intervention to encourage physical activity, healthy eating and lifestyle needs to start early.

Rapid results

In Australia, the Bondi Centre Youth Mental Health Programme has developed and implemented a programme of structured lifestyle support for young people with psychosis. This includes weekly individual counselling sessions with a dietitician and exercise physiologist, daily access to clinic-based gym facilities and regular exercise training sessions. There is also life and health coaching in learning to budget for, shop for and cook healthy meals. Individual dietary advice reduces waist circumference⁹, and the more comprehensive programme of physical activity and lifestyle intervention has been shown to tackle the early weight gain that troubles so many young people starting on antipsychotic medications. Over a period of 12 weeks, young people with first-episode psychosis took part in the lifestyle programme at Bondi, and outcomes were compared with those for a similar cohort who did not undergo screening or receive lifestyle support following their psychiatric diagnoses. Weight gain in the intervention group was a quarter of that seen in the standard of care group and only 13% of intervention patients versus 35% had clinically significant weight gain.⁶

Good for body and soul

In the USA, a randomized controlled trial (STRIDE) has also shown that in people taking antipsychotic medications, weight loss and lifestyle interventions can help support and maintain weight loss.^10,11,12,13 Encouraging and enabling a healthy lifestyle and greater physical activity among young people with serious mental illness improves body image and health-related self-efficacy.¹² In people with first-episode psychosis, physical activity as part of the programme of care aids long-term symptomatic and functional recovery.¹⁴

Rapid weight gain in young people with newly diagnosed schizophrenia is a common phenomenon

The accumulating evidence is that physical health issues and cardio-metabolic risks in young people with psychosis are real health threats that merit, and can respond to, clinical management and intervention strategies. Such programmes are probably best delivered by a mental healthcare team joining forces with the broader multidisciplinary team to tackle and improve long-term quality of life for all young, newly-diagnosed people with psychosis.

Equal priority from the start

The HeAL declaration, which evolved at the 2010 International Early Psychosis Association conference, stated that any young person developing psychosis should expect their physical health to be given equal priority to their mental health. They should expect their physical health complications, two years after diagnosis, to be equivalent to those of their peers.¹⁵