CLINICAL HANDBOOK OF SCHIZOPHRENIA

426 VI. SPECIAL POPULATIONS AND PROBLEMSrelated to diabetes management, even when they have more medical visits. Schizophreniamay be more strongly associated with underutilization of preventive services compared toother psychiatric diagnoses. Substance use increases the risk of underutilization of services,despite the fact that substance abuse is itself a risk factor for medical illness.Potential BarriersIn the same manner that schizophrenia requires lifelong management, most medical conditionsdemand a long-term focus on lifestyle changes and medical management. However,certain features of schizophrenia make it difficult for patients to engage in healthybehaviors. For example, negative symptoms may contribute to low energy and low motivationto perform physical exercise regularly or to maintain a healthy diet. Similarly, socialwithdrawal may prevent persons with schizophrenia from leaving the home to engagein physical exercise or to shop for healthy foods.A range of factors potentially prevents persons with schizophrenia from seeking necessarymedical services. Cognitive and motivational difficulties associated with schizophreniacontribute to a decreased capacity to identify significant medical symptoms or torecognize that a medical condition warrants attention. Motivational difficulties and/orthought disorder associated with schizophrenia can also affect desire to engage in selfcareor to follow through with recommended preventive health recommendations. In thiscontext, medical follow-up and self-management may be especially challenging. Otherpotential barriers to adequate and appropriate care include problems with medication adherenceand inadequate knowledge about chronic medical conditions. See Table 41.1 fora summary of potential barriers to effective medical care.Difficulty with transportation, lack of health insurance, or other financial limitationscan make follow through on medical appointments difficult. Interacting with the medicalhealth care system can also be challenging and even overwhelming. For example, impairedsocial and communication skills associated with schizophrenia can directly affectthe ability to call for a medical appointment and or to communicate with physicians duringa medical visit. Social withdrawal, verbal or cognitive difficulties, perceived stigma, orfear may contribute to a reluctance to communicate medical symptoms clearly during anoffice visit. At the same time, medical providers frequently are inexperienced in dealingwith schizophrenia. For example, increased preoccupation with an important physicalsymptom may be dismissed as a psychiatric symptom or as a part of the mental illness.Unfortunately, this failure to address medical problems appropriately is mirrored by themental health system when mental health providers lack experience in detecting and caringfor physical illnesses.At the systems level of care, the lack of integration between mental health and medicalservices constitutes a major barrier. A variety of models are being evaluated in re-TABLE 41.1. Potential Patient Barriers to Effective Medical Management• Inadequate knowledge about the chronic disease• Negative symptoms• Low motivation• Low energy• Denial• Social withdrawal• Cognitive or verbal difficulties• Fear• Financial constraints• Inadequate health insurance coverage• Lack of transportation