CLINICAL HANDBOOK OF SCHIZOPHRENIA

41. Medical Comorbidity 425Medical disorders among persons with schizophrenia frequently are related to preventablelifestyle factors, such as smoking, alcohol and drug abuse, unsafe sexual practices,obesity, poor diet, and lack of exercise. In addition, antipsychotic medications generallyincrease the risk for weight gain or medical illness, including diabetes. Consequently, obesity,smoking, and diabetes are important topics in primary care visits for persons withserious mental illness. When addressing lifestyle and the management of medical conditions,it is important to be aware that certain clinical features of schizophrenia (e.g., cognitivedeficits and negative symptoms associated with lack of motivation and difficulty inplanning and initiating behaviors) may pose additional challenges in terms of adherence.The housing, residential, and financial situation can similarly present difficulties (e.g.,reduced ability to select healthy diet choices).ImpactOn average, persons with serious mental illness die approximately 10 years earlier thanpersons in the general population, frequently due to medical causes. In addition to prematuremortality, medical conditions also have a negative impact on physical functioningand quality of life. Poor physical health and functioning are associated with reduced capacityto participate in critical life activities, including work, social relationships, leisureactivities, and activities of daily living. Acquired physical disabilities, frailty, and the burdenof multiple medical problems, commonly associated with old age, can in personswith schizophrenia have their onset in middle age. Sometimes the physical functioning ofpersons with schizophrenia resembles that of significantly older individuals in the generalpopulation.Chronic medical conditions in the general population are frequently associated withgreater use of medical services. However, persons with schizophrenia may actually havelower hospitalizations rates for procedural interventions compared to persons in the generalpopulation (e.g., related to heart disease; Lawrence, Holman, & Jablensky, 2001).There is no clear consensus in the research literature on whether persons with schizophreniause fewer medical services (perhaps indicating inadequate health care) or greateramounts of acute medical services (possibly reflecting a more severe course of illness andpoor ongoing management). Some studies identify higher rates of outpatient visits,whereas others identify lower rates. The relationship between comorbid medical illnessand cost of overall care for persons with schizophrenia remains largely unexplored. However,Dixon and colleagues (2000) observed that persons with schizophrenia and diabeteshave higher health care service utilization and expenditures compared to persons withschizophrenia and no diabetes.Quality of ServicesOne factor that contributes to increased mortality for persons with schizophrenia is lowerquality of medical services. For example, Druss and colleagues (2001) reported that personswith schizophrenia were more likely than persons without a mental illness to die after aheart attack. Their study also found that these greater rates of mortality were in part explainedby lower quality care and a failure to provide the same level of guideline-basedcare following a heart attack for persons with schizophrenia as that provided for the generalpopulation.Other studies indicate that persons with schizophrenia spectrum disorders receive similaror lower rates of general preventive follow-up care compared to the general population.Furthermore, it appears that persons with schizophrenia and diabetes receive fewer services