INTL. J. PSYCHIATRY IN MEDICINE, Vol.

41(3) 245-251, 2011

SCHIZOPHRENIA: MEDICAL ILLNESS,

MORTALITY, AND AGING*

DAVID A. CASEY, MD
University of Louisville School of Medicine, Kentucky

MERCEDES RODRIGUEZ, MD
VA Healthcare System, Miami, Florida
COLLEEN NORTHCOTT, PH.D., MD
University of British Columbia, Canada
GARRY VICKAR, MD
Washington University, Missouri and
St. Mathews University, British Virgin Islands
LINA SHIHABUDDIN, MD
Mt. Sinai School of Medicine, New York

ABSTRACT
Objective: Schizophrenia is a devastating and common psychiatric disorder
which is associated with a high degree of medical morbidity and reduced
life span in addition to psychosis. In this article, these problems will be
discussed in the context of schizophrenia and aging. Method: The recent
literature was reviewed using Pubmed, Medline, and Google scholar with
the search terms schizophrenia, aging, medical problems. Results: Schizo-
phrenia is associated with significant medical morbidity and mortality.

*An early version of the article was presented as a workshop at the American Psychiatric
Association annual meeting, in San Francisco, California in May 2009.

245

2011, Baywood Publishing Co., Inc.

doi: 10.2190/PM.41.3.c
http://baywood.com
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Diabetes and cardiovascular disease, along with smoking and obesity,

are over-represented and contribute to reduced quality of life and life span.
Schizophrenics often receive poor medical care. Conclusions: The impacts
of schizophrenia on physical health and successful aging have been under-
estimated. Psychiatrists and primary care physicians need to address the
overlapping medical and psychiatric aspects of the disorder while the medical
care system for these patients requires a much higher degree of coordination
than is currently available.
(Intl. J. Psychiatry in Medicine 2011;41:245-251)

Key Words: schizophrenia, aging, medical problems

INTRODUCTION
Schizophrenia is among the most severe psychiatric disorders. Current estimates
of prevalence range from about 0.5% to 2% of the population worldwide in
various surveys [1]. A study of elderly schizophrenics revealed a prevalence of
about 0.44% [2]. As this demographic group expands with the aging of the
American population, the absolute number of elderly schizophrenics may be
expected to increase substantially. Because of the confluence of aging, age-related
disease, social marginalization, and the effects of schizophrenia itself, the
suffering of this group is likely to be magnified. Elderly patients from minority
groups are especially vulnerable [3]. Despite these factors, elders are not well
represented in the schizophrenia literature. In this article, we will examine some
of the important issues and controversies surrounding schizophrenia and aging,
with a focus on medical morbidity, mortality, and barriers to care.

MEDICAL ISSUES, MORBIDITY, AND MORTALITY

Schizophrenics in the United States have a significantly reduced average life
span. Some studies suggest a life-span diminishment of 20%, or more than
15 years [4, 5]. Many factors seem to contribute to this problem. The death
rate from suicide and accidents is substantially elevated, especially in young
adulthood [6]. During mid and late life, the high burden of medical co-morbidity
plays a substantial role. Alcohol, substance abuse, and particularly smoking also
contribute. Adherence to medical therapy is often poor in schizophrenic patients.
For a variety of reasons, access to medical care is often limited, and the quality
of care is often poor [3-5].
Schizophrenics are vulnerable to a variety of medical problems which greatly
affect quality of life as well as contributing to reduced average life span. These
medical disorders impact many different bodily systems. Many of these processes
begin earlier in life, but are fully manifested in their impact on aging and mortality
 SCHIZOPHRENIA: MEDICAL ILLNESS, MORTALITY, AND AGING / 247

[3-5, 7]. Cardiovascular disease is the single most important source of medical
morbidity and mortality, although several additional factors are likely to con-
tribute. Mortality from cardiovascular disease is more than twice as common
among schizophrenics compared with the general population. The high rate of
smoking, diabetes mellitus, hypertension, obesity, and hyperlipidemia in this
group is linked to cardiovascular disease. Many older schizophrenics have a
sedentary lifestyle and fast-food diet high in saturated fat, calories, salt, and
sugar but low in nutritional value [3, 5, 8]. Diabetes mellitus, type II, is also more
common among schizophrenic patients as is diabetes associated mortality [9, 10].
Obesity is common in schizophrenia. In general, schizophrenics have a low rate
of physical exercise. These factors contribute to and interact with elevated
cholesterol and lipids in predisposing to atherosclerosis and heart disease. This
combination of obesity (as measured by elevated BMI or body mass index) and
elevated cholesterol along with type II diabetes is sometimes known as the
metabolic syndrome [11]. The metabolic syndrome is greatly over-represented
in schizophrenic patients, particularly women, and is clearly associated with
elevated cardiovascular risk. In the Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) trial, schizophrenic men were 138% and women 251%
more likely to have metabolic syndrome than a control group [11]. Atypical anti-
psychotics are clearly associated with weight gain and account for much of the
elevated risk of the metabolic syndrome. A recent review suggested that metabolic
changes begin within weeks of initiation of therapy with these medications
[12]. However, medication alone does not seem to fully explain this condition.
The relative contribution of medication and the other various factors, as well as
the possible role of the schizophrenic illness itself, remains to be elucidated.
Elderly demented patients have an increased death rate when treated with
atypical antipsychotics. The relevance of this observation to elderly schizo-
phrenics is uncertain.
Respiratory disorders are also more common among schizophrenics than the
general population. The high prevalence of chronic obstructive pulmonary
disease (COPD) is probably related to high rates of smoking. Schizophrenic
patients have also been reported to have an elevated incidence of tuberculosis
[13]. In addition to tuberculosis, several other infectious diseases occur with
high prevalence in schizophrenia. HIV as well as hepatitis B and C are also more
common [14]. Periodontal disease, dental caries, and overall poor dentition
contribute to poor nutrition, and are a risk factor for endocarditis [15]. The
elevated risk of these infectious diseases appears to be related to impaired judg-
ment, high risk behaviors, and life in a marginalized social setting.
Data on schizophrenia and cancer are not clear. Some studies suggest an
elevated risk of lung and esophageal carcinomas, probably related to smoking
and alcohol consumption. There is a longstanding theory that cancer has a
reduced incidence in schizophrenia, and that this observation may be linked
in some way to the etiology of the disorder. To date, studies have generated mixed
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results [16, 17]. A number of studies have revealed a low rate of rheumatoid
arthritis (RA). An inflammatory process has been hypothesized in schizophrenia
as a possible etiologic factor, suggesting a possible link, although the nature
of such a link remains obscure. Some authors have suggested a possible genetic
factor protecting against RA in schizophrenia [18].
Schizophrenic patients are also impacted by extrapyramidal side effects
of antipsychotic medications throughout the life span, and the risk of tardive
dyskinesia is probably cumulative. However, elderly patients clearly have an
elevated risk of extrapyramidal symptoms [19].
Despite the frequency and impact of these problems, the quality of medical
care available to schizophrenic patients is poor. Schizophrenic patients are
substantially less likely than others to have regular contact with a primary care
physician with appropriate health screening and evaluation for disorders such
as diabetes, hypertension, and hyperlipidemia. Even when they enter medical
treatment, schizophrenics are less likely to receive recommended screening
and treatment. For example, assessment of glycosolated hemoglobin is less
than half as likely to occur in schizophrenic patients with co-morbid diabetes.
Schizophrenic patients who suffer myocardial infarction are significantly less
likely to have coronary artery catheterization, angioplasty, or coronary artery
bypass grafting. Pharmacologic management after myocardial infarction is also
lacking. These patients are less likely to be prescribed aspirin, beta blockers, or
other appropriate measures [5].

BARRIERS TO CARE
The current model of care does not serve the schizophrenic patient well,
particularly those with medical co-morbidity. Coordination of care among
medical, social, and psychiatric providers is often poor. Continuity of care among
inpatient and outpatient providers is also lacking. Insurance programs designed
to pay for care may unfortunately also create barriers. Patient-related factors
play an important role in impeding delivery of services in schizophrenia. Lack
of adherence to medical and psychiatric regimens is a common problem in
the treatment. Paranoia focusing on the treatment, executive dysfunction, lack
of awareness of illness, and unavailability of treatment services all play a role
[20, 21].
Poor organization of service systems also plays a significant role in this
problem. Lack of coordination among medical, psychiatric, and social service
providers is a major issue. In many communities, housing and social services
for schizophrenic patients are lacking [22]. Many schizophrenics see only a
psychiatrist (if they see a physician at all), who may not be trained to fully
manage their co-morbid medical conditions. Conversely, non-psychiatric physi-
cians typically receive little training in psychiatry or the impact of psychiatric
illness on medical care, and schizophrenic patients are often unsuccessful in
 SCHIZOPHRENIA: MEDICAL ILLNESS, MORTALITY, AND AGING / 249

accessing these providers [23]. Insurance programs designed to facilitate care

can also create barriers. Managed care standards (especially for inpatient care)
which were designed for commercial insurance programs often do not take
into account the medical, social, and often legal requirements of caring for this
group of patients. Poorly coordinated pharmacy benefit, formulary, and pre-
certification programs often lead to gaps in medication, or frequent medication
changes, which contribute to relapse and re-hospitalization [24].

CONCLUSIONS AND RECOMMENDATIONS

Schizophrenia is a complex phenomenon with important psychiatric, medical,
and social dimensions. Its sufferers are at risk for diminished function and quality
of life. Executive and cognitive dysfunctions are present from the onset of
schizophrenia and complicate management of medical co-morbidity as well as
psychotic symptoms. Schizophrenic patients are subject to an elevated risk of a
variety of medical conditions, especially diabetes, the metabolic syndrome, and
cardiovascular disease. Their lifestyle, diet, medications, smoking, and lack of
medical care contribute to a greatly diminished life expectancy. Medicine has an
ethical obligation to do better in addressing these complex problems. The nature
of an illness marked by paranoia and executive dysfunction means that many
patients will not be able to seek out medical care on their own, and may require
case management and support for healthy living. The current medical, psychiatric,
and social service system often fails these patients.
Aging schizophrenics are substantially less likely than others to receive appro-
priate medical care, even when presenting themselves to a medical institution. In
an ideal situation, psychiatrists and primary care medical providers would work
side by side in the same centers, which would also offer outreach, case manage-
ment, and social services. Psychiatrists would be trained to help more actively
manage medical issues, while primary care physicians would receive more complete
psychiatric instruction. A rational payment system would remove the seams and
gaps in accessing care, including case management, and access to medications.
In the future, a focus on primary medical care, weight management, smoking
cessation, health screening, and optimal management of diabetes, hyperlipidemia,
and cardiovascular disease should be as important in management of schizo-
phrenia as treatment of psychotic symptoms. Research should concentrate on
improved understanding of the medical problems of schizophrenics as well
as improved systems of care.

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Direct reprint requests to:

David A. Casey, MD
Associate Professor
Senior Vice-Chair and Head of Clinical Services
University of Louisville School of Medicine
Department of Psychiatry and Behavioral Sciences
401 E. Chestnut St., Suite 610
Louisville, KY 40202
e-mail: david.casey@louisville.edu