**3. Causes of poor physical health in mental illness**

A number of reasons exist to explain the poor detection of physical health problems in patient with mental illness. Some patients are unaware of any physical health problems, usually a consequence of cognitive deficits associated with their mental illness (Goldman, 1999). Often there is a reluctance to seek medical help and when it sought patient with mental health find it difficult to describe their problems to a medical practitioner, or present with atypical medical symptoms. Patient with schizophrenia have been shown to have a high tolerance for pain and subsequently are less likely to report this symptom (Dworkin, 1994). Another complexity concerns the effects of psychiatric illness on perceived physical health. For example, depression can lead to an increase in perceived physical symptoms and worsening of subjective health outcomes.

The management of medical conditions is a complex and problematic issue, arising largely because of the separation of medical and psychiatric health care services. The stigma of mental illness is one obvious barrier preventing psychiatric patients from receiving adequate physical health care, as some physicians may be uncomfortable in working with this patient. Another concern is managing physical conditions where patients that have an increased prevalence with psychiatric illness and where there is a general lack of treatment compliance. The challenging task of managing physical illness with this patient requires skill, patience and experience as patients often present late with complications. (Table 1)


Table 1. Barriers to health care for patients with mental illness. Adapted from Goldman.

#### **3.1 Lifestyle risk factors**

In recent years, there is a growing concern about physical illness in patients with mental illnesses, specifically the risk of cardiovascular disease. Those patients are more likely to be overweight, to smoke, to have hypertension, hyperglycemia or diabetes, and dyslipidemia (Table 2).

Dyslipidemia and Mental Illness 353

Other risk factors are attributable to unhealthy lifestyle, including social scale such as

Concerning diet, a study (Mc Creadle, 2003) examined in detail the dietary intake of 102 people with schizophrenia in Scotland. Their fruit and vegetable consumption averaged 16

Brown et al, 1999 and Mc Creadle, 2003 found that patients with schizophrenia tended to take only small amounts of exercice. Factors such as features of the illness, sedative

Psychotropic medication is associated with a host of physical complications and side effects. Old antipsychotic medication was associated with neurologic side effects, including involuntary movement disorders, such as akathisia, parkinsonism, tardive dyskinisia. New antipsychotics are more commonly use. Despite the low propensity of new antipsychotics towards extra pyramidal side effects other adverse effects associated with them include excessive weight gain, metabolic disturbances. Medical conditions attributed to the use of typical and atypical antipsychotic medication include diabetes, hyperlipidemia, and cardiovascular disease: specifically hypertension and cardiac arrhythmias, obesity (Meyer,

Much attention has been focused on the metabolic syndrome which brings together a series of abnormal clinical and metabolic findings which are predictive of cardiovascular risk. The most commonly used definition for the metabolic syndrome are the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP), (Jama, 2001) and the adapted ATP-III-A proposed by the American to Heart Association following the American Diabetes Association lowering of the threshold for impaired fasting glucose 100mg/dl.

Another recent definition, by the International Diabetes Federation (Alberti et al, 2006; Sarafidis &, Nilsson, 2006) stressed the importance of waist circumference, using

Waist (cm) M>102, F>88 M>102, F>88 M≥94,F≥80 Blood pressure ≥130/85\* ≥130/85\* ≥130/85\* HDL cholesterol (mg/dl) M<40, F<50 M<40,F<50 M<40,F<50 Triglycerides (mg/dl) ≥150 ≥150 ≥150 Fasting glucose (mg/dl) ≥110\*\* ≥100\*\* ≥100\*\*

Table 3. Definitions of metabolic syndrome: The metabolic syndrome has been shown to be an important risk factor for the development of both type 2 diabetes and cardiovascular

ATP III A 3 out of 5 criteria required

IDF waist + 2 criteria required

ATP III 3 out of 5 criteria required

unemployment, poorer financial standing, poor diet and sedentary behaviour.

medication and lack of opportunity and general motivation may be relevant.

portions per week, less than half the recommended intake.

**3.2 Medication** 

2002; Davidson, 2002).

**4. The metabolic syndrome** 

(Quindy et al, 2005 ; Alberti et al, 2006).

ethnic/race specific criteria (Table 3).

\*or treated with antihypertensive medication \*\*or treated with insulin or hypoglycemic medication

disease.


Table 2. Estimation prevalence and relative risk 5 (RR) of modifiable cardiovascular disease risk factors in schizophrenia and bipolar disorder compared to the general population. Adapted from Correll, 2007

## **3.1.1 Obesity**

Excessive body weight increases the risk of morbidity from number conditions, including hypertension, dyslipidemia, type II diabetes, coronary heart disease. Excess abdominal fat is associated with dyslipidemia, hypertension and glucose intolerance. Risk of comorbid diseases has been shown to rise as BMI increases above 25 kg/m2. In psychiatric practice, weight gain is a long recognized and commonly encountered problem. A study of patients with schizophrenia reported 51% of males and 59% of females to be clinically obese, compared with 33% of people with other psychiatric disorders. This study provided an estimate of mean weight gain in patients who received standard doses of antipsychotics over 10-week period. The mean increases were 4.45 kg with clozapine, 4.15 with olanzapine, 2.92 kg with sertindole, 2.10 kg with risperidone, and 0.04 kg with ziprasidone (Allison & Casey, 2001). It is important to note that substantial weight gain is associated with both atypical (eg, clozapine, olanzapine) and conventional (eg, thioridazine, chlorpromazine) antipsychotics.

#### **3.1.2 Smoking**

The prevalence of smoking greatly exceeds that in the general population (Table 1) Heavy cigarette smoking is intimately associated with schizophrenia and it may have implications for the underlying neurobiology of the disease. Smoking is a good example of how behavior and treatment interact to increase morbidity at a number of levels. It is a risk factor for respiratory and ischemic heart disease and stroke. Cigarette smoking induces hepatic microsomal enzymes, which increase the metabolism of psychotropic medication, reducing plasma levels of antipsychotics notably olanzapine and clozapine. It may influence the patient's behavior and the treatment outcome. Therefore smokers usually require greater levels of antipsychotic medication than non-smokers to achieve similar blood levels.

#### **3.1.3 Diabetes**

It is another risk factor for coronary atherosclerosis that is associated with metabolic abnormalities that result in changes in the transport, composition and metabolism of lipoproteins.

#### **3.1.4 Hypertension**

Is a cardiovascular risk factor as it produces structural changes within the arteries. The seq uel of hypertension are greatly affected by comorbidities such as dyslipidemia, smoking, diabetes, lack of physical activity, sodium intake, and stress.

Estimated prevalence, % (RR) Modifiable risk factors Schizophrenia Bipolar disorder Overweight 45–55% (1,5–2) 21–49% (1-2) Smoking 50–80% (2-3) 54-68% (2-3) Diabetes 10-15% (2) 8-17% (1,5-2) Hypertension 19-58% (2-3) 35-61% (2-3) Dyslipidemia 25-69% (≤5) 25-38% (≤3) Metabolic syndrome 37-63% (2-3) 30-49% (1,5-2) Table 2. Estimation prevalence and relative risk 5 (RR) of modifiable cardiovascular disease risk factors in schizophrenia and bipolar disorder compared to the general population.

Excessive body weight increases the risk of morbidity from number conditions, including hypertension, dyslipidemia, type II diabetes, coronary heart disease. Excess abdominal fat is associated with dyslipidemia, hypertension and glucose intolerance. Risk of comorbid diseases has been shown to rise as BMI increases above 25 kg/m2. In psychiatric practice, weight gain is a long recognized and commonly encountered problem. A study of patients with schizophrenia reported 51% of males and 59% of females to be clinically obese, compared with 33% of people with other psychiatric disorders. This study provided an estimate of mean weight gain in patients who received standard doses of antipsychotics over 10-week period. The mean increases were 4.45 kg with clozapine, 4.15 with olanzapine, 2.92 kg with sertindole, 2.10 kg with risperidone, and 0.04 kg with ziprasidone (Allison & Casey, 2001). It is important to note that substantial weight gain is associated with both atypical (eg, clozapine, olanzapine)

The prevalence of smoking greatly exceeds that in the general population (Table 1) Heavy cigarette smoking is intimately associated with schizophrenia and it may have implications for the underlying neurobiology of the disease. Smoking is a good example of how behavior and treatment interact to increase morbidity at a number of levels. It is a risk factor for respiratory and ischemic heart disease and stroke. Cigarette smoking induces hepatic microsomal enzymes, which increase the metabolism of psychotropic medication, reducing plasma levels of antipsychotics notably olanzapine and clozapine. It may influence the patient's behavior and the treatment outcome. Therefore smokers usually require greater

levels of antipsychotic medication than non-smokers to achieve similar blood levels.

It is another risk factor for coronary atherosclerosis that is associated with metabolic abnormalities that result in changes in the transport, composition and metabolism of

Is a cardiovascular risk factor as it produces structural changes within the arteries. The seq uel of hypertension are greatly affected by comorbidities such as dyslipidemia, smoking,

and conventional (eg, thioridazine, chlorpromazine) antipsychotics.

diabetes, lack of physical activity, sodium intake, and stress.

Adapted from Correll, 2007

**3.1.1 Obesity** 

**3.1.2 Smoking** 

**3.1.3 Diabetes** 

lipoproteins.

**3.1.4 Hypertension** 

Other risk factors are attributable to unhealthy lifestyle, including social scale such as unemployment, poorer financial standing, poor diet and sedentary behaviour.

Concerning diet, a study (Mc Creadle, 2003) examined in detail the dietary intake of 102 people with schizophrenia in Scotland. Their fruit and vegetable consumption averaged 16 portions per week, less than half the recommended intake.

Brown et al, 1999 and Mc Creadle, 2003 found that patients with schizophrenia tended to take only small amounts of exercice. Factors such as features of the illness, sedative medication and lack of opportunity and general motivation may be relevant.

### **3.2 Medication**

Psychotropic medication is associated with a host of physical complications and side effects. Old antipsychotic medication was associated with neurologic side effects, including involuntary movement disorders, such as akathisia, parkinsonism, tardive dyskinisia. New antipsychotics are more commonly use. Despite the low propensity of new antipsychotics towards extra pyramidal side effects other adverse effects associated with them include excessive weight gain, metabolic disturbances. Medical conditions attributed to the use of typical and atypical antipsychotic medication include diabetes, hyperlipidemia, and cardiovascular disease: specifically hypertension and cardiac arrhythmias, obesity (Meyer, 2002; Davidson, 2002).
